web-based information services in critical environments: an

University of WollongongResearch Online

University of Wollongong Thesis Collection University of Wollongong Thesis Collections

2008

Web-based information services in criticalenvironments: an investigation of an intensive carewebsite to model professional-publiccommunicationKholoud AlkayidUniversity of Wollongong

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Recommended CitationAlkayid, Kholoud, Web-based information services in critical environments: an investigation of an intensive care website to modelprofessional-public communication, Doctor of Philosophy thesis, Faculty of Commerce, University of Wollongong, 2008.http://ro.uow.edu.au/theses/1748

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Web-based Information Services in Critical Environments: an investigation of an intensive care website to model professional-public

communication

A thesis submitted in fulfilment of the requirements for the award of the degree of

DOCTOR OF PHOLOSOPHY

from

THE UNIVERSITY OF WOLLONGONG

by

KHOLOUD ALKAYID

M.B.A. Degree in Business Administration/ University of Jordan B.Sc. Degree in Business Administration/ University of Jordan

INFORMATION SYSTEMS

2008

ii

CERTIFICATE

I, Kholoud Jamal AlKayid, declare that this thesis, submitted in fulfilment of the

requirements for the award of Doctor of Philosophy of Information Systems, in the

Faculty of Commerce, University of Wollongong, is wholly my own work unless

referenced or acknowledged. This document has not been submitted for qualifications at

any other academic institution.

Kholoud AlKayid

28/02/2009

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TABLE OF CONTENTS

CERTIFICATE ......................................................................................................................................... II LIST OF TABLE ...................................................................................................................................... VI LIST OF FIGURES ............................................................................................................................... VII LIST OF ABBREVIATIONS ............................................................................................................... VIII ABSTRACT .............................................................................................................................................. IX PUBLICATION FROM THE RESEARCH .......................................................................................... XI ACKNOWLEDGEMENTS ................................................................................................................... XII CHAPTER 1: INTRODUCTION ............................................................................................................. 1

1.1 INTRODUCTION ................................................................................................................................... 1 1.2 BACKGROUND .................................................................................................................................... 3 1.3 STATEMENT OF PROBLEM ................................................................................................................... 6 1.4 THE RESEARCH QUESTIONS AND APPROACH ..................................................................................... 7 1.5 OUTCOME AND SIGNIFICANCE OF THE RESEARCH ............................................................................ 10

1.5.1 Outcome of the Research ......................................................................................................... 10 1. 5.2 Significance of the Research ................................................................................................... 11

1.6 OVERVIEW AND ORGANISATION OF THE THESIS ............................................................................... 13 1.7 AN OVERVIEW OF THE THESIS .......................................................................................................... 13

CHAPTER 2: THE LITERATURE REVIEW ...................................................................................... 18 2.1 INTRODUCTION ................................................................................................................................. 18 2.2 AN OVERVIEW OF COMMUNICATION ................................................................................................ 19 2.3 COMMUNICATION AND INFORMATION NEEDS OF FAMILY MEMBERS OF CRITICALLY ILL PATIENTS 25

2.3.1 Information Needs ................................................................................................................... 25 2.3.2 The Nature of communication between healthcare providers and patients and their families 30

2.4 ONLINE HEALTH INFORMATION SERVICE ......................................................................................... 43 2.4.1 Introduction ............................................................................................................................. 43 2.4.2 Internet Web-based Information systems ................................................................................. 43 2.4.3 Interaction Design ................................................................................................................... 52 2.4.4 Human-Computer interaction .................................................................................................. 55

2.5 SYSTEMS DYNAMICS MODELLING .................................................................................................... 57 2.5.1 Literature of System Thinking and System Dynamics .............................................................. 57 2.5.2 Cases of System Modelling in Health Care ............................................................................. 67

2.6 ACTIVITY THEORY ........................................................................................................................... 71 2.6.1 An Overview of Activity Theory ............................................................................................... 71 2.6.2 Activity Theory and Information Systems ................................................................................ 74 2.6. 3 The Principals of Activity Theory ........................................................................................... 76

2.7 CHAPTER SUMMARY ........................................................................................................................ 79 CHAPTER 3: THE RESEARCH DESIGN AND METHODOLOGY ................................................ 81

3.1 INTRODUCTION ................................................................................................................................. 81 3.2 THE ICU AS A CRITICAL CASE OF THE WIDER RESEARCH PROBLEM ................................................ 83 3.3 DATA COLLECTION AND ANALYSIS FROM ICU STAKEHOLDERS ...................................................... 85

3.3.1 State-based staff as owners and developers of the Website ..................................................... 86 3.3.2 ICU Administrators and Clinicians ......................................................................................... 87 3.3.3 Families of patients .................................................................................................................. 92

3.4 THE PROCESS OF DEVELOPING THE SYSTEM DYNAMICS MODEL ................................................... 100 3.4.1 System Dynamics modelling and its suitability for this research ........................................... 100 3.4.2 STELLA Software .................................................................................................................. 102

3.5 APPLYING ACTIVITY THEORY TO THE RESEARCH PROBLEM .......................................................... 104 3.5.1 Step-by-Step use of Activity as the Unit of Analysis for Research ......................................... 104

3.6 CHAPTER SUMMARY ...................................................................................................................... 108

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CHAPTER 4: DATA COLLECTION AND ANALYSIS ................................................................... 110 4.1 INTRODUCTION ............................................................................................................................... 110 4.2 THE RESEARCH CONTEXT .............................................................................................................. 110

4.2.1 Design and use of a Particular WBIS for ICUs ..................................................................... 110 4.2.2 Intensive Care Units .............................................................................................................. 115

4.3 THE VIEW FROM THE STATE-BASED STAFF AND WEB-SITE DEVELOPERS ......................................... 118 4.4 THE VIEW FROM STAFF IN ICU UNITS ............................................................................................. 121 4.5 THE VIEW OF PATIENTS’ RELATIVES .............................................................................................. 124 4.6 COMPARISON WITH ANOTHER AUSTRALIAN HEALTH WEBSITE ...................................................... 133

4.6.1 The Usability Tests ................................................................................................................ 133 4.6.2 Results and recommendations based on the analysis of the Usability Tests .......................... 134

4.7 CHAPTER SUMMARY ...................................................................................................................... 136 CHAPTER 5: DEVELOPMENT AND PRESENTATION OF THE MODEL ................................ 138

5.1 INTRODUCTION ............................................................................................................................... 138 5.2 A SYSTEM DYNAMICS STUDY OF COMMUNICATION IN ICUS ......................................................... 139 5.3 THE CONCEPTUAL MODEL DESIGN ................................................................................................ 141

5.3.1 The Stocks and Flows ............................................................................................................ 142 5.3.2 Adding converters and linking Stocks and Flows .................................................................. 145 5.3.3 The Evolution of the Conceptual Model ................................................................................ 148

5.4 MODEL VALIDATION ...................................................................................................................... 152 5.5 CHAPTER SUMMARY ...................................................................................................................... 155

CHAPTER 6: THE ACTIVITY THEORY ANALYSIS .................................................................... 157 6.1 INTRODUCTION ............................................................................................................................... 157 6.2 THE PROCESS OF USING ACTIVITY THEORY ................................................................................... 158

6.2.1 Description of the Analysis Process ...................................................................................... 159 6.2.2 Identifying the Core Activities of the System being Investigated ........................................... 159 6.2.3 Identifying the Mediating Elements and Tools ...................................................................... 160 6.2.4 Identifying the Activities that Support the Core Activity ........................................................ 161

6.3 INITIAL ANALYSIS - WITH THE PATIENT CARE ACTIVITY AS CORE ACTIVITY ............................. 162 6.3.1 The Core Activity ................................................................................................................... 162 6.3.3 Supporting Activities .............................................................................................................. 163

6.4 SUBSEQUENT ANALYSIS WITH COMMUNICATION BETWEEN ICU STAFF AND FAMILIES AS THE CORE ACTIVITY OF INTEREST ........................................................................................................................ 165

6.4.1 The Core Activity ................................................................................................................... 165 6.4.2 The Mediating Elements and Tools........................................................................................ 166 6.4.3 Supporting Activities .............................................................................................................. 168 6.4.4 Implications of this Activity System ....................................................................................... 169

6.5 CHAPTER SUMMARY ...................................................................................................................... 174 CHAPTER 7: RESEARCH DISCUSSION AND RESULTS ............................................................. 176

7.1 INTRODUCTION ............................................................................................................................... 176 7.2 FINDINGS FROM THE DATA COLLECTED FROM STAKEHOLDERS ....................................................... 177 7.3 FINDINGS FROM THE SYSTEMS AND ACTIVITY MODELLING ............................................................ 179

7.3.1 The System Dynamics Model ................................................................................................. 179 7.3.2 The Activity Theory Model ..................................................................................................... 181

7.4 DISCUSSION OF MAIN FINDINGS ..................................................................................................... 182 7.5 CHAPTER CONCLUSION .................................................................................................................. 186

CHAPTER 8: IMPLICATIONS OF THE RESEARCH .................................................................... 189 8.1 INTRODUCTION ............................................................................................................................... 189 8.2 REVIEW OF THE STUDY AND RESULTS ............................................................................................ 189 8.3 CRITICAL SUMMARY OF THE INNOVATIVE RESEARCH TECHNIQUES USED ..................................... 193

8.3.1 Q-Methodology Concourse using Zing Groupware ............................................................... 193 8.3.2 Usability Testing .................................................................................................................... 194 8.3.3 System Dynamics Modelling .................................................................................................. 194 8.3.4 Analysis using an Activity Theory Framework ...................................................................... 195

8.4 LIMITATIONS OF THE STUDY .......................................................................................................... 196

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8.5 THE THEORETICAL AND PRACTICAL CONTRIBUTIONS .................................................................... 196 8.5.1 Research Contribution 1 ........................................................................................................ 196 8.5.2 Research Contribution 2 ........................................................................................................ 197 8.5.3 Research Contribution 3 ........................................................................................................ 198 8.5.3 The Practical Contribution .................................................................................................... 198

8.6 THE OPPORTUNITIES FOR THE FUTURE STUDY ............................................................................... 199 REFERENCES ....................................................................................................................................... 200 APPENDIX I USABILITY TEST SCENARIO1B-ICCMU ............................................................... 222 APPENDIX II: USABILITY TEST SCENARIO2B-ICCMU ............................................................ 224 APPENDIX III: USABILITY TEST SCENARIO3B-ICCMU .......................................................... 225 APPENDIX IV: USABILITY TEST SCENARIO1A- ICCMU ......................................................... 227 APPENDIX V: USABILITY TEST SCENARIO2A-ICCMU ............................................................ 229 APPENDIX VI: USABILITY TEST SCENARIO3A-ICCMU .......................................................... 230 APPENDIX VII: USABILITY TEST PRE-QUESTIONS-ICCMU .................................................. 231 APPENDIX VIII: USABILITY TEST POST QUESTIONS-ICCMU ............................................... 232 APPENDIX IX: USABILITY TEST SCENARIO1- CARESEARCH .............................................. 233 APPENDIX X: USABILITY TEST SCENARIO2-CARESEARCH ................................................. 234 APPENDIX XI: USABILITY TEST SCENARIO3-CARESEARCH ............................................... 235 APPENDIX XII: CARESEARCH WEB SITE PRE-TEST QUESTIONS ....................................... 236 APPENDIX XIII: CARESEARCH WEB SITE- POST TEST QUESTIONNAIRE ........................ 237

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LIST OF TABLE

TABLE 3.1: THE TYPES OF USABILITY TEST LABORATORY (RUBIN 1994) 96 TABLE 4.1: TYPES OF ICUS 116 TABLE 4.2: REGISTERED INTENSIVE CARE UNITS IN NSW 117 TABLE 4.4: SAMPLE OF PARTICIPANTS ANSWERS 128

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LIST OF FIGURES

FIGURE 1.1: ORGANISATION OF THIS THESIS 13 FIGURE 2.1: THE VYGOTSKIAN TRIANGLE 72 FIGURE 2.2: THE STRUCTURE OF A HUMAN ACTIVITY SYSTEM (ENGESTRÖM 1999) 73 FIGURE 2.3: LEONTIEV’S MODEL OF ACTIVITY LEVELS (VERENIKINA AND GOULD 1998) 73 FIGURE 2.4: LEONTIEV (1981) DEFINED ACTIVITY HIERARCHY AS ABOVE 76 FIGURE 3.1: THE MODEL OF THE QUALITATIVE RESEARCH PROCESS USED IN THIS

RESEARCH FOLLOWING MILES AND HUBERMAN (1994) 82 FIGURE 3.2: Q-SORT TRIANGLES FOR RANKING OF THE STATEMENTS 89 FIGURE 3.3: NUMBER OF DETECTED USABILITY PROBLEMS BY NUMBER OF TESTED

SUBJECTS 94 FIGURE 3.4: ATUL LAYOUT 100 FIGURE 3.5: STOCK FLOW DIAGRAM 103 FIGURE 3.6: INTERRELATED ACTIVITIES IN THE RESEARCH OF ENGESTROM (1999) 107 FIGURE 3.7: INTERRELATED ACTIVITIES IN THE RESEARCH OF HASAN & GOULD (2001) 108 FIGURE 5.1: THE STOCK UNDERSTANDING REFERS TO FAMILY MEMBERS. IT IS

INCREASED BY THE INFLOW INFORMING AND DECREASED BY THE OUTFLOW CONFUSING. 144

FIGURE 5.2: THE STOCK RELEVANT MEDICAL KNOWLEDGE REFERS TO ICU STAFF. IT IS INCREASED BY THE INFLOW UPDATING AND DECREASED BY THE OUTFLOW RELEASING. 144

FIGURE 5.3: THE STOCK PATIENT CRISIS LEVEL REFERS TO THE PATIENT’S CONDITION. IT IS INCREASED BY THE INFLOW WORSENING AND DECREASED BY THE OUTFLOW IMPROVING 145

FIGURE 5.4: THE CONFUSING FLOW WILL BE BASED ON THE AVERAGE OF THE STRESS LEVEL AND, THE INFORMING FLOW BASED ON THE AVERAGE OF KNOWLEDGE. 146

FIGURE 5.5: THE UPDATING IS BASED ON THE AVERAGE ICU KNOWLEDGE AND, THE RELEASING OF INFORMATION IS BASED ON THE AVERAGE OF QUESTIONS ASKED BY FAMILY MEMBERS 146

FIGURE 5.6: THE MEDICAL CONDITION OF THE PATIENT (IMPROVING OR WORSENING) AFFECTS THE AMOUNT OF INFORMATION THAT ICU STAFF GET AND, THE VARYING LEVEL OF NEED FOR COMMUNICATING WITH PATIENTS’ FAMILIES. 147

FIGURE 5.7: THIS ALL LEADS TO COMMUNICATION BETWEEN FAMILY MEMBERS AND ICU STAFF THROUGH FACE-TO-FACE COMMUNICATION, OR WBIS. 147

FIGURE 5.8: THE FIRST CONCEPTUAL STOCK/FLOW DIAGRAM THAT SHOWS A SIMPLE FLOW OF MEDICAL INFORMATION TO PATIENTS’ FAMILIES TO ENHANCE THEIR STOCK OF UNDERSTANDING, BASED ON INITIAL DISCUSSION WITH THE WEB-SITE OWNERS AND DESIGNERS IN THE STATE ICU COORDINATION UNIT 149

FIGURE 5.9: AN ENHANCEMENT OF THE MODEL OF FIGURE 5.8, USING THE LITERATURE AND DATA ANALYSIS. 151

FIGURE 5.10: THE CURRENT STATE OF THE CONCEPTUAL MODEL INTEGRATING THE THREE STOCKS WITH CONVERTERS AND CONNECTORS BASED ON THE LITERATURE AND ANALYSIS OF DATA FROM THE RESEARCH 152

FIGURE 6.1A: THE CORE ACTIVITY 162 FIGURE 6.1B: SUPPORTING ACTIVITY 1 163 FIGURE 6.1C: SUPPORTING ACTIVITY 2 164 FIGURE 6.2: THE HOLISTIC MODEL OF THE THREE ACTIVITIES IN THIS RESEARCH 164 FIGURE 6.3: COMMUNICATION AS A CORE ACTIVITY IN THIS RESEARCH 165 FIGURE 6.4: THE CORE ACTIVITY OF COMMUNICATION WITH MOST SIGNIFICANT

MEDIATING TOOLS. 167 FIGURE 6.5: THE ACTIVITY SYSTEM THAT MAKES COMMUNICATION THE CORE ACTIVITY

(A MORE SUITABLE CHOICE FOR THIS RESEARCH) 169

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LIST OF ABBREVIATIONS

3D 3 Dimensions

ATUL Activity Theory Usability Laboratory

CCN Critical Care Nurse

CCFNI Critical Care Family Needs Inventory

EMR Electronic Medical Records

HCI Human Computer Interaction

HIS Health Information Systems

ICCMU Intensive Care Coordination and Monitoring Unit

ICT Information and Communication Technology

ICU Intensive Care Unit

IS Information Systems

ISO International Standards Organization

IT Information Technology

NSW New South Wales

PS Patient Satisfaction

SD System Dynamics

SHCN Southern Health Care Network

WBIS Web-Based Information Systems

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ABSTRACT

Information and communications technologies (ICT), together with the growth of the

World-Wide Web, have brought about immense changes that provide new opportunities

for processing information and supporting communication. These opportunities can be

exploited through innovative information systems in important areas such as the one

addressed in this thesis, namely, the use of web-sites to link expert professionals with

the general public. The particular focus of the research reported here is the field of

health, where medical outcomes can be improved by various modes of information

exchanges between healthcare professionals and the public.

The research approach taken in this thesis acknowledges the complexity of the situation

in an ICU and the interrelationship of constantly changing organisational, human and

technical elements in a stressful context. In addition to information from the literature,

data is collected and analysed from three sets of ICU stakeholders (clinicians, families

of patients, State Health Department website owners) using three different techniques

suited to the context of the stakeholders. The results of this analysis feed into an

evolutionary System Dynamics modelling process, which both integrates the data and

literature, and also dynamically visualises the information flows between the different

stakeholders. The resulting model is then qualitatively reinterpreted using concepts and

frameworks from Activity Theory in order to provide deeper insights into the

relationships within the system.

The final stage of the research uses Activity Theory to further explore the relationships

between people, tools, processes and elements of the ICU environment. Activity Theory

is concerned with explaining and analysing human activity with a rich holistic

understanding of how people collaborate with the assistance of sophisticated tools in the

complex dynamic environments of modern organisations.

x

Findings from the data analysis supported the on-going evolutionary development of a

SD model using the stock and flow techniques of Stella software. System Dynamics

modelling is a general technique used to imitate, on computers, systems exhibiting

complex, time-dependent behaviour. In this case, a model was created to present the

information flows and accumulation of understanding during critical situations of

patient care in the ICU. Models can be used to investigate the system without disrupting

the real activity; a very important issue in the work of an ICU. It is possible to replicate

complex patterns of behaviour and gain insight about the interaction of variables in a

dynamic and holistic way that is not achievable in the traditional reductions and

objective approaches to research.

This study makes significant theoretical and practical contributions regarding online

professional-public communication and web-based information services.

This study highlights the importance of online information services for experts to

communicate with the public, particularly in advanced countries like Australia. The

findings, however, show that it is difficult to do this well and that initial attempts may

not meet the needs of intended users and hence not be well used.

The practical research contribution is significant in that it provides a method for

improving Health Care Web-Based Information delivery in Intensive Care

Environments.

In future research, the approach and results of this study could be used to examine

issues concerned with the use of the Web for information flows, knowledge transfer,

understanding and learning in different types of crisis situations that cannot easily be

studied by conventional research methods.

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PUBLICATION FROM THE RESEARCH

The following papers and publications have been produced from the research reported

in this thesis.

1- AlKayid, K. and Hasan, H. (2006). Patient Centered Information Systems for

Knowledge Transfer. Proceeding of (ACKMIDS). The Australian Conference on

Knowledge Management and Intelligent Decision Support, Melbourne Australia.

2- AlKayid, K., Meloche, J. and Hasan, H. (2008). Simulating Information Exchange in

Order to Investigate the Utility of Public Health Websites. Proceeding of (EMCIS).

European and Mediterranean Conference of Information Systems, 24-26 May 2008,

Dubai.

3- AlKayid, K. (2008). Online Health Services: a Study of Information needs of Family

Members of Critically Ill Patients in NSW Hospitals by Using System Dynamics

Modelling. Proceeding of Graduate Studies Research Conference. University of Jordan

12-14 May 2008, Jordan.

4- AlKayid, K. (2009). Public Information Services: Public Health Web-Based

Information Systems (WBIS) - Case Study. Accepted for The Second Conference For

The Faculty of Business, The University of Jordan, 14-15 April 2009, Jordan.

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ACKNOWLEDGEMENTS

In the completion of this research, I am indebted to many people for their assistance.

Firstly, I would like to express my deepest gratitude and appreciation to my supervisor

Associate Professor Helen Hasan for her invaluable contribution, continual support and

guidance throughout my research project. Her enthusiastic suggestions, critical

comments and feedback at each stage during my research inspirited and encouraged me

to accomplish this research. I would also like to express my special thanks to Dr Joseph

Meloche for his continued support and guidance and for his kind assistance in general.

I would also like to take this opportunity to thank the University of Wollongong,

particularly the Commerce Faculty staff, who were not only supportive, but very

accommodating and friendly.

I would also like to take this opportunity to thank my scholarship sponsors, Al-Balqa

Applied University in Jordon for funding my research over the last three years.

My heartfelt thanks go to my family, especially my parents, brothers and sisters for their

unfailing support and encouragement throughout my program and especially during my

difficult times.

My beloved husband Dr. Aiman, the last in this list but the first in my thoughts, for your

love, encouragement and support. I intent to make my family – and especially my kids –

proud of my efforts, as they have endured all kinds of circumstances for the past three

years throughout my studies. Therefore, I dedicate my work to my small family.

1

CHAPTER 1: INTRODUCTION

1.1 INTRODUCTION

This thesis takes an innovative research approach to address the problem of how

professionals inform and communicate effectively with relevant members of the public

in high-stress situations. A multifaceted, qualitative study of information flows in

hospital Intensive Care Units is used to highlight the role of web-based technologies in

providing information to support communication between professionals and the public

leading to better outcomes for all concerned.

The area of public healthcare has always been particularly information intensive, with

health authorities having to be engaged in collecting, disseminating and communicating

information long before the advent of computers. Information and communications

technologies (ICT), together with the growth of the World-Wide Web, have brought

about immense changes that provide many new opportunities for processing information

and supporting communication. These opportunities can be exploited in innovative

information systems, which can improve health outcomes by supporting information

exchanges between healthcare professionals and the public. However, web-based

information systems (WBIS), which inform and connect people directly or indirectly,

are complex and dynamic, and can best be understood as the interrelationship of

organisational, human and technical elements (Boland & Tenkasi 1995). When

conducting research in this area it is essential to take a holistic approach that integrates

the latest ICT tools and processes with the needs of all stakeholder groups. The research

presented in this thesis adopts such an approach to understand the role of a website in

meeting the information needs of critically ill patients in Intensive Care Units (ICU)

2

(Molter 1979). It does this through the use of System Dynamics modelling to visualise

information flows and communication between clinicians and the members of a

patient’s family and Activity Theory to bring the focus onto the main activities of the

communication and the purpose for which information is used.

The communication between medical professionals and the general public can often be

difficult due to time limitations, cultural differences and even language barriers (Ton et

al. 2005; Ruiz-Moral et al. 2006). When a loved one is admitted to an ICU, families are

often in crisis and have emotionally charged responses arising from stress, anxiety and

confusion, which affects their ability to understand the information presented to them

(Thorne et al. 2006; Lloyd & Bor 2004). Their lack of scientific knowledge may make

it difficult for them to absorb the medical information that is provided to them

(Auerbach et al. 2005; Azouly et al. 2003). However, clinicians working in critical care

units can play a vital role in helping patients and their families cope with the emotional

distress associated with these crisis situations (Azouly et al. 2005). This study explores

the nature of communication in such crisis environments from the perspectives of both

the families and clinicians. It aims to provide a greater understanding of how

information technologies can be used to resolve some of the problems that currently

arise within regular yet ad-hoc, face-to-face communication that occurs (Coiera 1997).

This research takes a comprehensive, dynamic and inclusive view of the complex issues

of communication that exist between healthcare providers and family members of

critically ill patients in the dynamic and high stress environment of ICUs. It addresses

efforts to support face-to-face information exchanges with material put together by

experts on a public website in a language that the general public can understand. The

research takes an integrated systemic view of these initiatives by collecting qualitative

data from three sets of stakeholders, namely: 1) those developing the web service, 2) the

3

ICU clinical staff and, 3) the families of patients. The study uses this data, together with

insights from the literature, to model the information flows of an ICU, using a System

Dynamics technique to explore and display the issues in a dynamic and holistic way in

order to gain a greater understanding of the communication process and the role of the

website in this process. The resulting conceptual model is then qualitatively

reinterpreted using concepts and frameworks from Activity Theory in order to provide

deeper insights into the relationships within the system.

Activity Theory provides a particular, holistic definition of human activity in its

historical and cultural context that can be adopted as a holistic unit of analysis for

research into complex situations such as those in the critical care circumstances of an

ICU. The models become a means of presenting this understanding to all stakeholders

whose feedback informs further improvements to the models, which can in turn inform

practice.

The study identifies the complex relationships between ICU staff’s desire to

communicate and family members’ need for information to be met through a mix of

traditional communication (face-to-face) and online health information services.

Complications arise from the clinicians’ use of medical terms and the family’s anxiety

in crisis situations, which affects their ability to comprehend effectively. The study has

produced models that assist in understanding the dynamics and future direction of such

situations in a holistic manner.

1.2 BACKGROUND

This research is motivated by an ongoing project involving a team of university

researchers and a central Coordination and Monitoring Unit for ICUs in the New South

Wales (NSW) State Health System. The research presented in this thesis aims to study a

4

web-based service designed by the Unit to meet the information needs of administrators

and clinicians in the ICUs of their public hospitals. The research addresses not only the

technological considerations, but also the needs and situations of a variety of

stakeholders. The stakeholders include the staff of the Coordination and Monitoring

Unit, who initiated and now manage the design and content of the website, the clinicians

and administrators in the hospitals’ ICUs, patients and their families as well as members

of the general public. To provide an integrated and holistic view, data for the research is

collected and analysed from all stakeholder groups in an appropriate and contextual

manner as will be described later in the study.

The website contains pages that serve a number of purposes including an open section,

which covers general intensive care information for health professionals, and a

password protected section with formal state guidelines for ICU clinicians. However,

the focus of the study presented here is a third, public section of the website, which

serves to aid the process of communication between ICU staff and the families of

patients in the ICU. A great deal of effort and expertise has been put into the accuracy

of the content of the material on this part of the site and to ensure that it is presented in

an understandable way. This includes translations of a large part of the content into

languages other than English for immigrant communities within the State. While this

communication is ‘patient–centred’, the patient in an ICU is usually not in a position to

use a computer and unlikely to be a direct user of the system. Others form the

stakeholder community for the system and so their input is sought for the research.

This research draws on secondary data from existing literature, although there is not a

great deal of specific research done in this area. The study also collects primary data

from the three identified stakeholder groups, namely, staff in the central coordination

and monitoring unit responsible for the design and content of the web service, the

5

administrators and clinicians in ICUs at various state hospitals and families of patients

in ICUs. In addressing the ethical issues of obtaining data from this third group of

stakeholders, the patients’ families surrogate research subjects are used in order to

determine their information needs and to evaluate the utility of the website in supporting

these needs.

The research approach here acknowledges the complexity of the situation and the

interrelationship of organisational, human and technical elements in a stressful context.

Much of the data collected in this study are qualitative and subjective, but none the less

valid and constructive. Extra value comes from its multifaceted nature and the

modelling processes, which both integrate the data and literature, and also visualise the

relationships between the different views. A System Dynamics model using the stock

and flow techniques embody the information flow and accumulation of understanding

during critical situations in ICUs in a dynamic and holistic way. This is followed by an

analysis of stakeholder activities using an Activity Theory framework.

The approach to systems thinking in this research uses the concepts of stocks and flows,

traditionally applied to physical materials. According to Richmond (2004), stocks

represent conditions within a system (i.e. how things are). Flows represent the activities

that cause conditions to change. This research adapts these basic elements of systems

dynamics to look at flows of information and stocks of knowledge. SD modelling is a

general technique used to imitate, on computers, systems exhibiting complex, time-

dependent behaviour (Sterman 2000). As this research adopts a qualitative paradigm,

conceptual SD modelling is appropriate and constructive. As will be shown in Chapter

5, it is possible to depict complex patterns of behaviour and gain insight about the

interaction of dynamic variables in a realistic and holistic way that is not achievable in

the traditional reductionist and objective approaches to research.

6

Activity Theory is significant for information systems research. As will be described in

Chapter 2, it explains the effects of tools and environment on human beings’ actions,

reactions and behaviours at work and in people’s relation with technology in general.

The theory has a basic structure for application, but is flexible in its nature and can be

applied on different researches in different fields. The theory has undergone stages of

development since the Russian psychologist Vygotsky developed it, and is still dynamic

and capable of more adjustment and development. The results of the Activity Theory

analysis are described in Chapter 6.

The data collection and its analysis, together with the SD modelling and the activity

analysis are undertaken in a qualitative, interpretive fashion.

1.3 STATEMENT OF PROBLEM

The research problem of this thesis is the difficulties of communication and information

flows between professionals and involved members of the public in crisis situations and

the role of computer technologies in providing information to support professional-

public communications.

Solving this problem is important as better medical outcomes can be achieved through

improved modes of information exchanges between healthcare professionals and the

public. One such mode involves web-based systems, which informs and connects

people directly or indirectly, as medical exchanges often take place under complex and

dynamic conditions of stress and distress. However, rapid technological advancement is

resulting in even more complex social systems.

The ICU is chosen as the site for this research as it is one of those crisis areas where

communication is difficult. In this situation, the professionals frequently lack the time

and opportunity required to adequately communicate with non-professionals, such as

7

patients and their family members. Admission to ICUs often comes without warning, so

families are suffering, shocked, helpless, and confused. Family coping resources are not

readily mobilised at such times, and the healthcare team is understandably focused on

severely ill or injured patients. Consequently, family needs and concerns are commonly

overlooked, or become secondary to caring for the patient.

The communication in ICUs between families (the public) and ICU staff (professional)

is used as an example of communication and information exchange issues in critical and

crisis situations. The focus of the research is a particular online health information

services for ICUs in NSW. The intended practical outcome of the research is to enhance

the development of their web-based information system. The theoretical outcome is to

better understand the role of technology while communicating in dynamic social

systems.

1.4 THE RESEARCH QUESTIONS AND APPROACH

To examine the points previously discussed and address the issues raised, the

primary research questions are:

1. What is the nature, type and context of communication between healthcare

providers and the families of critically ill patients in ICUs?

2. What are the perceived communication needs of healthcare providers and

information needs of family members of critically ill patients that can be usefully

accommodated with a Web-Based Information Service?

3. How can a holistic, interpretive research approach improve the understanding of

the nature of communication in crisis environments?

8

4. How can the result of this study inform the broader question of ICT support for

professional-public communication?

Traditional research approaches are no longer sufficient to solve the growing

complexities of these types’ of research problems, which raise the need to use modern

research methods to understand dynamic and complex ICT issues. Following the

literature review, the research project will be tackled in three atypical phases in order to

answer these questions:

The first phase, reported in Chapter 4, collects data to evaluate from the perspective of

three sets of stakeholders: the evolving Online Heath Information Services for ICUs

which is provided by the Intensive Care Coordination and Monitoring Unit, NSW

Health.

The WBIS is intended as an information source for families. It provides basic facts

about the functions and operations of an ICU and aids in answering some of the most

commonly asked questions in the ICU. The research addresses not only the

technological considerations, but also the needs and situations of a variety of

stakeholders. The stakeholders include the staff of the Coordination and Monitoring

Unit, who initiated and now manage the design and content of the website, the clinicians

and administrators in the hospitals’ ICUs, patients and their families as well as members

of the general public. To provide an integrated and holistic view, data for the research is

collected and analysed from all stakeholder groups in an appropriate and contextual

manner.

The second phase of the research involves the conceptual SD model. This stage is based

on one of the modern SD tools that is the Stock and Flow model using the appropriate

software. The results of the literature review and the analysis of the data from the first

9

phase of the research is used to inform the building of the model. This is done in an

evolutionary manner with feedback from stakeholders and other researchers. It is used

to improve each version of the model.

This phase of this study explores the communication issues by building a System

Dynamics ‘stock and flow’ model using STELLA software to support, represent and

visualize information flows and subsequent increases in understanding within critical

environments. The model provided a means of re-interpreting the data, encapsulating

the knowledge gained from the study and visualising the research findings in an

innovative way that enables the project to move forward.

The final phase of the research uses Activity Theory to further explore the situation as

an activity system. Activity Theory is an approach to conceptualising relationships

between individuals, communities, technologies and activities. It can be considered as a

tool to mediate human interactions with the world (Kuutti 1999). Activities are dialectic

relationships between subjects and objects (i.e. people doing things), mediated by tools

and the processes of their use. Activity theory is concerned with explaining and

analysing human behaviour in complex systems, such as those found in an ICU.

Activity Theory places the focus of analysis on the activities that are carried out by

people in support of their interpretations of their role, the opportunities and resources

available to them, and their purpose for which the activity exists. This is both

subjective, in the sense that it is a matter for individual interpretation, and objective, in

the sense that the motives, purpose and context are a vital part of the reality of human

work.

With information from the literature, and from data collected and analysed from three

sets of ICU stakeholders (clinicians, families of patients, State Health Department

website owners), this research focuses on a deeper theoretical understanding of online

10

health information services for the public through holistic System Dynamics and

activity-based models. The intended practical outcome of the research is to enhance the

development of WBIS.

1.5 OUTCOME AND SIGNIFICANCE OF THE RESEARCH

1.5.1 Outcome of the Research

This study uses qualitative analysis from multiple stakeholders to create System

Dynamics and Activity-based models and thereby provide insightful explanations of the

nature of communication and information flow provided by ICU caregivers to family

members with the influence of relevant elements identified in this context. The results

provide an increased understanding about the more general subject of communication

between professionals and the public in similar situations.

Models are used to depict the use of traditional verbal communication which is

supplemented by communication that occurs via a website developed by a State ICU

Coordination Unit. This research data analysis is based on interviews with the website

development group management, where an initial conceptual model of the system was

developed showing how the families’ understanding of the situation in critical care

depended on the supply of information. Then, more advanced conceptual model is

developed in an evolutionary fashion; informed by a review of the literature, as well as

the collection and analysis of data from various stakeholder groups.

As the research focussed on online health information services for the public in NSW a

practical outcome of the research is knowledge to enhance the development of their

WBIS.

11

In future research the approach and results of this study could be used to examine issues

concerned with the use of the Web for information flows, knowledge transfer, as well as

understanding and learning in different types of crisis situations that cannot easily be


1. 5.2 Significance of the Research

This study makes significant contributions in different areas, namely, theory, practice

and research methods.

This study contributes to theoretical knowledge, specifically on information flows

between family members of critically ill patients and clinical staff in Intensive Care

Units and more generally between professionals and the public in crisis environments.

This is particularly important as ICT tools such as WBIS are becoming increasingly

popular and sophisticated.

The research contribution is significant in that it provides knowledge for improving

Health Care Web-Based Information delivery in Intensive Care Environments. The

theoretical research contribution of this study derives from the development of

conceptual model for explaining the nature of communication in complex and stressful

environments.

This study makes the following significant theoretical and practical contributions

towards the online communication and information services area.

1. This is unique in that it uses conceptual SD modelling together with Activity

Theory concepts to investigate communication and information flows.

2. This study highlights the importance of online information services for

experts to communicate with the public, particularly in advanced countries like

Australia.

12

3. Most importantly, this research used different in-depth qualitative approaches

to provide a holistic overview and understanding of online communication

between professionals and communities.


improving Health Care web-based information delivery in Intensive Care environments.

From the perspective of research methods, this study demonstrated the use of novel

qualitative data gathering and analysis techniques using:

*Q-methodology support by ICT based group decision-making tools

*Usability testing with scenarios based on an Activity Theory approach

*System Dynamics modelling using Stella software

*Underpinnings from an Activity Theory framework

13

1.6 OVERVIEW AND ORGANISATION OF THE THESIS

This dissertation is organised into eight chapters as shown in Figure 1.1.

Figure 1.1: Organisation of this Thesis

1.7 AN OVERVIEW OF THE THESIS

This thesis essentially addresses communication and information exchanges between

healthcare providers and family members of patients in critical care settings, as an

instance of professional-public communication using WBIS in crisis environments.

Chapter 8 - Research Implications

Chapter 1 - Introduction

Chapter 2 – Literature

Chapter 3 - Research Design & Methodology

Chapter 4 – Data Collection & Analysis

Chapter 7 - Discussion & Results

Chapter 5– Development and Presentation of the Model

Chapter 6 -The Activity Theory Analysis

14

This thesis consists of eight chapters:

1.7.1 Chapter 1: Background and Introduction to the study

This chapter has presented a broad overview of the research study including,

introduction and background to the study, research motivation, the research goals,

and the significance of the study. It presents the research questions and discusses

how the research can contribute to improving the health care system through

improving the communication system (WBIS), which provides clear, detailed and

confidential information to the public in the state.

1.7.2 Chapter 2: Literature Review

This chapter presents a review of the relevant literature of communication in

general. Related issues to this study are reviewed and included in this chapter, as is

communication between health providers and families in critical care settings. This

is followed by an overview of the literature on Web-Based Information Systems

(WBIS), with brief literature on HIC and interaction design. Then, the last part is

about using SD modelling in a health care setting. It provides a detailed historical

overview of Activity Theory.

1.7.3 Chapter 3: Research Design and Methodology

It describes the research methodology that is used to collect data, and describes and

justifies the case of communication between clinicians and patient families within

the context of hospital intensive care units as a valid instance of the wider research

problem.

A qualitative research approach guides the study by interviewing the management of

the website about the development and rational of the website. Then, Q

methodology is adapted to evaluate the online health information from the

15

perspective of ICU staff. After that, a usability test is carried out to investigate the

information needs of family members of critically ill patients by using an online

health information service.

Suitable methods of data collection from each group are designed as follows:

State-based staff – Interview and documentation on the rationale for the website

ICU administrators and clinicians – A Q-method concourse on their subjective

views of the situation, collected from representative hospitals across the state.

Families of patients – Activity-based usability tests simulating the real situation in a

Usability Laboratory.

This chapter presents the basics of SD modelling, a brief description of Activity Theory

and an explanation of its usefulness in the analysis of complex problems, such as this

case presents. It also provides the explanation and justification of how the Activity

Theory can be used to understand and explain the nature of communication in ICUs in

terms of the social-cultural context.

1.7.4 Chapter 4: Data Analysis

This chapter presents the data analysis and reports the results related to the data

collected from three sets of stakeholders, namely: 1) those developing the web service,

2) the ICU clinical staff and 3) the families of patients.

Chapter four also provides some brief background on the Intensive Care units in the

state of New South Wales (NSW), Australia, about the Health Care Web-Based

Information Systems (WBIS), and the NSW Intensive Care Coordination and

Monitoring Unit (ICCMU), which is available to provide the general medical

knowledge to the NSW public and the professionals.

16

1.7.5 Chapter 5: Development and Presentation of the Model

This chapter describes how the modelling work was developed using the Stella software

to represent the role of the website in communication between the ICU and patient’s

families. The model is based on the analysis of extensive information that is gathered

from the three stakeholders of the web-based information service about the information

needs of critically ill patients’ families and their experience with such critical crisis

situations.

In this chapter the advanced conceptual model is presented that was developed in an

evolutionary fashion. It is informed by a review of the literature, as well as the

collection and analysis of data from various stakeholder groups. The SD model uses

Stella software (ISEE Systems 2006) to explore and display the issues in a dynamic and

holistic way to understand the nature of communication in ICUs.

1.7.6 Chapter 6: The Activity Theory Analysis

This chapter presents the Activity Theory analyses of the communication in the ICU. As

the main objective of this study is to provide a better understanding about the

communication and information in critical crisis situations, as is the case in ICU

settings, the Activity Theory approach is used to generate the holistic picture and the

suggestions of possible future improvements to current WBIS.

1.7.7 Chapter 7: Research Discussion and Results

This chapter presents the data analysis collected from the different target groups of the

study. This chapter also presents the discussion of the findings and introduces the key

conclusions from this study. It outlines recommendations and suggestions to assist in

improving the website provision of the information service extended to the families, in

order to achieve the required level of satisfaction for its users.

17

1.7.8 Chapter 8: Research Implications

It presents the implications related to the research questions of the study’s research

problem, and then discusses the contributions of this study within the context of the

literature. The chapter also identifies the limitations of the study and provides

suggestions for future research opportunities.

18

CHAPTER 2: THE LITERATURE REVIEW

2.1 INTRODUCTION

Rapid technological advancements have resulted in more complex social systems within

which Information and Communications Technologies (ICT) play a significant,

supportive role. The research reported in this thesis was motivated by the challenges

faced in the design of a web-based Information System to support the communication

between ICU staff and families of patients in Intensive Care Units (ICU). This is seen as

an example of communication and information exchange issues between professionals

or experts and the public in critical and crisis situations, where research is needed to

better understand the role of technology to supplement traditional face-to-face

communication in dynamic social systems.

This chapter shows how researchers and academics have studied this issue both in

general and in the particular case of the communication and information needs of

critically ill patients’ family members. It begins with an overview of literature on

communication before reporting on findings from previous studies on the information

needs of family members of patients admitted to ICUs. It then introduces issues

concerned with the communication between the families and the ICU clinicians.

Research into an online health information system is presented in the forth section of the

chapter. The fifth section presents an overview of the literature on system thinking and

System Dynamics modelling, reporting studies that use conceptual and simulation

modelling in the health environment are reviewed. Modelling is extended in the sixth

section, which details the fundamentals of Activity Theory can assist in the

understanding of interconnected activities such as those concerned with information

19

flows. System Dynamics modelling and Activity Theory form the basics of the research

modelling for data analysis and display in the thesis. The way, in which is done is

described as part of the methodology in Chapter 3.

2.2 AN OVERVIEW OF COMMUNICATION

Dwyer (2005, p.4) defines communication as ‘any behaviour, verbal, nonverbal or

graphic that is perceived by another’. Communication involves cooperation, and the

sharing of information (Lettau 1997). The communication process according to Hardy et

al. (1999) involves using signs and symbols to relate information in order to achieve

mutual understanding and preferred outcomes.

According to Craig (1999) communication theories are relevant to all aspects of the

practical life world but particularly so in the healthcare environment, where

communication is pivotal and richly meaningful. Therefore a background understanding

of communication theories is important to this thesis.

The four types of communication include (Dwyer as cited in Taylor, Rosegrant and

Meyer 1986):

1. Intrapersonal communication: within an individual who is feeling and thinking

2. Interpersonal communication: conversation between two people

3. Public communication: from one source to a number of receivers

4. Mass communication: reaching out to the wider public. For instance, an

organization reaches out to its public through media and advertising.

Communication involves the exchange of information, which involves messages sent to

the receiver who acknowledges the information received and understood by providing

feedback to the sender. Communication also involves cooperation, mutual agreement,

sharing and exchanging messages using signs and symbols that can be understood by all

20

those involved in the communication process (Stewart, 1966).

According to Lewis & Slade (1994) verbal communication can be either spoken or

written. On the other hand, non-verbal communication can be through any means that

adopts mainly graphics and includes the use of body language and movements. Body

language, also referred to as kinesics, expresses one’s non-verbal codes by the use of the

entire body. Another expression of non-verbal communication is haptics, a code relating

to the use of touch along with proxemics, which shows the use of space between

interacting members as a meaning system. The use of time is also taken into

consideration when communicating with others. This is formally known as chronemics.

This factor relates to both cultural context and expressions of tense. Non-verbal

communication has three major functions:

1. It involves codes that are not derived from spoken languages

2. The codes used are conventional and culturally specific

3. The meaning of non-verbal interaction is heavily influenced by the surrounding

context.

Understanding and interpreting these codes relies on one’s grasp of the codes. This

method of expressing one’s self is a powerful means of communication, which we as

humans use and interpret almost every time we encounter and start communicating with

someone, even if it is unintentional. For example, smiling is a conventional way to

express happiness, sympathy and pleasure, in most cultures. Many bodily actions are

essential modes of expressing our emotions, which we all share with other humans.

Graphics are also used to communicate ideas and information through visual shapes and

diagrams (Lewis & Slade, 1994).

According to Coiera (1997), traditionally the richest communication processes occur

during face-to-face interactions where communication process includes verbal and non-

21

verbal communication such as body language and graphic communication. However we

now rely more and more on distance communication channels include telephone, fax,

voicemail and Internet.

The complexity of any communication system arises from the number of people and

processes involved. As discussed by the Coiera (2003) complex systems are common in

health care as, for example, even a single process of patients discharge summary may

involve all of the following individuals:

1. Patients and their nominated third party, such as patient's relatives, clinicians, an

insurance company, etc.

2. Doctor, nurse, office clerk and information systems manager

3. Other hospital staff including medical registrars, specialists, ward clerks and

medical transcriptions

Hence, the communication system involves people, the message to be sent, the

technology to send the message and the organizational structure, which determines the

conversation that can occur. Communication systems can therefore broadly include the

following components (Coiera, 2003):

• Communication channel – face-to-face, through telecommunications, such as

telephone, emails and computational channels.

• Type of message – data, task and template oriented.

• Communication policies – bound by formal procedure.

• Agents – are involved in different information tasks. That minimizes

interruption and increases communication efficiency.

• Communication service – various communication services including voice

communication through telephone lines, fax transmission, voicemail or text

message using a mobile phone.

22

• Communication device – communication services can run on different

communication devices, which include telephone, fax, personal digital assistant

(PDA) internet, email and other technological devises, which today continue to

evolve.

The interaction mode is some systems are such that they require urgent attention, such

as a ring tone of a phone. Other systems do not interrupt and do not have a ring tone,

e.g., emails.

According to Coiera (1997) poor communication can have economic consequences. For

example, in healthcare, good and clear interpersonal skills are essential for healthcare

workers, as poor communication can result in treatment errors. This then has

implications for health outcomes, a point that strengthens the importance of research

such as the work of this thesis.

Particular instances of communication in this thesis are those between government and

the public and between experts and lay people. The growth of the Internet has changed

the manner in which such communications occur. A study by Welch and Fulla (2007)

investigates the virtual interactivity between government and citizens. The purpose of

their study is to measure the effect of Internet-based technology on the interactivity

between citizens and public organizations by developing a theoretical model of cyber-

interactivity and proposing about how virtual communication may effect change in

organizations and communities, using McMillan’s model of cyber-interactivity has four

constructs:

1. Content sophistication

2. Feedback opportunity

3. Dialogue complexity

4. Responsiveness

23

Their example of this phenomenon is in the Chicago Police Department where citizen

feedback, e-mail and police responses were collected over a 21 month period from the

advent of their web site on September 28th, 2000 through June 30th, 2002. They

concluded that virtual exchange leads to mutual development of virtual boundaries in

the shared inter locator space. According to this model, cyber-interactivity reduces the

role of mediation and makes it possible for citizens and government to redefine their

sense of community. Another finding, of particular relevance to the study in this thesis,

was that interactivity is more complex than is typically acknowledged in public

administration and political science literature. The evolution of the cyber-exchange

process requires an increasing level of resources, expertise and effort.

Bimber (1999) addresses the related issues of Internet and citizen communication with

government. The main idea in this study was that the Internet increases the flow of

communication between citizens and government, thereby, altering the patterns of

influence between elites and the mass public in terms of independent variables such

education, gender, skill level, social or political connectedness, need for services in

previous studies, etc . However, the communication medium was absent from their

theories, and Bimber claimed that the Internet adds a new possibility to the mix saying

that the form of communication has an effect on contact that is independent of other key

variables such as education and gender, the environmental and the social context.

The Internet may be broadening the democratic base of those who express themselves to

the government. On the other hand, floods of e-mails from citizens acting without

lasting convictions about public problems, or lasting interest do not add to democratic

discourse, or provide much of a guide to elected officials. Bimber (1999) suggests that

expanding communication capacity may have both positive and negative kinds of

consequences for American democracy.

24

Althaus and Tewksbury (2000) address the question of whether the web is likely to

replace or augment traditional news media by examining news consumption patterns

through members of a fully networked university community. The variables in their

study are: desirability of control, political knowledge, computer anxiety, and time spent

using various media for specific purposes. The behaviour of respondents in their sample

suggests that entertainment rather than news content is more likely to lose audience

members to the web, than using the web as a source of news. Also, the analysis of

people who have computer access and the skills needed to integrate the web into their

routine mix of media channels found evidence that the web supplements traditional

news media, which is consistent with recent studies exploring similar issues (Davis &

Owens 1998; Hughes Hill 1998; Pew Research Centre for the People and Press 1996b,

1998).

Within the medical profession, communication is heavily influenced by the doctor’s

individual ability to adapt and understand their patient’s communication methods and

styles in order to be able to transmit messages and signals effectively and improve the

overall efficiency in communication. Effective communication is synonymous with

good teamwork and is essential for the correct delivery of secure and healthy patient

care. In order for this to occur, doctors are expected to be dedicated, display respect,

understanding and interest in their patient’s prospects, opinions and be able to make

mutual shared decision making and provide clear succinct information to meet the needs

of the patient. Executing communication effectively is considered as an imperative

competence that is of much assistance to doctors because it assists them in allowing

their clinical capacitates to develop (Ruiz-Moral et al. 2006).

25

2.3 COMMUNICATION AND INFORMATION NEEDS OF FAMILY

MEMBERS OF CRITICALLY ILL PATIENTS

2.3.1 Information Needs

Many researchers and clinicians recognize the needs of the families of critically ill

patients particularly in an intensive care unit (ICU) where the patient may be unable to

speak for themselves. There is also the importance of reducing feelings of uncertainty,

confusion and helplessness when their loved one is admitted to an ICU. Many previous

studies have paid attention to addressing and meeting the information and emotional

needs of family members as is now discussed.

Molter (1976) investigates the needs of families in the ICU setting. In structured

interviews of 40 relatives of patients, who were critically ill, Molter found the needs

reported as most important, in ranked order, are

1. Feel that there is hope

2. Feel that the hospital cares about the patient

3. Have the waiting room near the patient

4. Be called at home about the patient’s conditions

5. Know the prognosis

6. Have questions answered honestly

7. Know specific facts about the patient’s prognosis

8. Receive information about the patient once per day

9. Be given explanations in understandable terms, and

10. Be allowed to see the patient frequently

Subsequently, Leaske (1986) developed the Critical Care Family Needs Inventory

(CCFNI); and it is an instrument that has been used extensively in most studies of

26

families in critical care settings. CCFNI was designed to measure the relative

importance of 45 items of the needs of family members of critically ill patients. In 1991,

she identified five domains and perceived needs of relatives of ICU patients to be: 1)

Information, 2) Comfort, 3) Support, 4) Assurance, and 5) Proximity.

Further to that, Warren (1998) uses the (NMI) instrument in a study to investigate how

well the perceived needs are met or unmet, rather than to rank the importance of the

need statement by using CCFNI. It is significant that the confidence and information

needs are the most important needs among patients and their families (Molter 1979;

Leske 1986; and Norris & Grove 1986).

Many researchers report that nurses and families have different perceptions of family

needs in ICUs, e.g. Bouman 1984, Forrester and Murphy 1991. In a recent study, Kosco

and Warren (2000) use the NMI to investigate the perceived needs of nurses in the

critical care unit compared with the perceived needs of family members in a critical care

waiting room. The discussion of this study states that the families found it more

important to have a specific person to call at hospital than the nurses when they are

unable to visit and to have someone be concerned with their relative’s health; they

perceived that the need to visit anytime was being met.

Other studies of families in critical care settings investigate family anxiety (Rukholm et

al. 1991), coping (Azouly et al. 2005 and Koller 1991), information needs (Hughes et al

2004), and stress (Azouly et al. 2003, Auerbach et al. 2005 and Van Horn 2000). For

the most part, these studies also ask family members to rate inventories that captured

only those behaviours and experiences delineated by the instrument. Since quantitative

studies limit representation of families' experiences in the ICU, qualitative studies that

further explore their perceptions are essential.

Another study of families in critical care settings has investigated family needs by

27

exploring the perceptions of families and ICU staff. In this study, Bijttber (2001) reports

the staff generally underestimates relatives’ needs that both nurses and physicians

underestimate the relatives' need for information and the proximity to the patient. On

the individual need items, the nurses generally underestimate relatives’ needs, but in

some cases overestimations are found. This study also asks the three groups to rank 45

CCFNI items, which shows that the participant’s experience of a heightened need for

information is especially great among patients and their relatives. However, many

admissions to intensive care units are unplanned and admitted as an emergency. This

creates a group of people who are not psychologically prepared for critical illness, or the

critical care environment. It is crucially important that suitable information also be

provided to the families of this group.

Although many studies have attempted to address the needs of family members in ICU

settings, minimal data are available on the effect of nurse staff roles in terms of

satisfying family members. Clarke & Aiken (2003) point out that a nurse gathers and

transmits information between health care providers and patient’s family members.

A Canadian study of 47 ICU nurses from a 9-bed ICU in a south-western Ontario

hospital, aims to describe the nurses’ perception with regard to meeting family needs

(Al-Masri & Fox-Wasylyshyn 2007). They found that the ICU nurses are satisfied with

their performance regarding the family needs of critically ill patients during

hospitalization compared with their colleagues’ performance, and they would be able to

act as the main source of information to critically-ill patients’ relatives about the ICU

environment and their family member’s medical condition.

Many studies address the collaboration between a critically ill patient’s family and staff

and the family’s involvement in the care. Azoulay et al. (2003) explore the differences

between the perceptions of families and caregivers about the family involvement in the

28

medical care of their patients, and how this affects helping family members deal with

emotional depression. Through the results, the perspectives of ICU staff are obtained,

revealing a major theme “88%” encourage families to participate. On the other hand, a

small proportion of respondents of family members feel they can share in providing

medical care with ICU staff. In a critical illness situation, because family members are

frequently required to make important life decisions, this crucial decision-making

heightens their anxiety.

One of the consistently cited primary needs of patients’ families is the need for

information, as well as, good family-nurse interactions (Molter 1979). Another study by

Hickey and Lewandowski (1988) found that the most important issue for family

involvement with nurses in ICUs was related to the patients’ death and the nurses’

feelings about the family.

Good nurse/family communication is important because it assists the patient and family

in coping with the critical period of admission to the ICU. In a subsequent study,

Azouly et al. (2005) use the impact of Event Scale scores and a post-traumatic stress

reaction through telephone interviews with family members of patients who are

discharged or dead after admission to intensive care unit. The main focus of their

research deals with possible associations between information and participation in end

of life decisions on the one hand and emotional distress on the other hand. The main

findings to emerge are that the family members of critically ill patients experienced

heightened levels of emotional distress that are unmet information needs and

involvement in end-of-life decisions.

Furthermore, there is evidence to link family satisfaction with the information they

obtain and their emotional distress level. Auerbach et al. (2005) & Azoulay et al. (2003)

report that more interpersonal contact with ICU staff encourages family members to

29

participate in the patient’s care, and this leads to a reduction in the high levels of

depression and anxiety often found in family members of critically ill patients. Similar

results were presented by Soderstotm et al. (2003), which explore the staff’s views of

interactions between nursing staff and relatives of patients in ICU settings in Swedish

hospitals.

Engeström & Söderberg (2005) study the perspectives of critical care nurses (CCN)

towards the families in the ICU; due to lack of research about critical care nurses

experiences of and views on the significance of close relatives in intensive care. This

study shed the light on the subject through focus group discussions with 24 CCN in four

focus groups during the spring of 2004 in Sweden.

Close relatives are important in this situation and like to be near and close to get

information about their relatives; therefore mutual understanding is necessary if CCNs

are to support those relatives as a good resource, both for critically ill people and for

themselves.

In general, CCNs want to give the close relatives some hope, but at the same time be

honest. This statement agrees with Burr (2001), who writes that the hope for close

relatives is that the critically ill patient survives, and if that is no longer possible, they

have a peaceful death. As a result close relatives become more important to CCN, and

as Holden et al. (2002) show, the development of the relationship between CCNs and

close relatives demands time and energy, but also helps to reduce stress for all those

concerned. Therefore, CCNs and physicians need to improve their co-operation,

especially concerning the planned care for the critically ill people with close relatives;

how these relatives are given information; and, if CCNs want to improve their work,

they need to give more individual nursing care to the critically ill people.

30

Most studies involving families in the critical care setting take place in the coronary

care unit (CCU) or medical-surgical ICU. No qualitative studies have been conducted

with families in the neurological ICU.

Azoulay et al. (2000) report that half of the family members in their study do not

understand what the physician explained to them. Also, the technical words interfere

with the nurse–family communication process (Zazpe 1996).

In a crisis situation, such as an ICU, relatives may have severe difficulty processing and

retaining information because as a person’s level of arousal increases, the ability to

process complex information decreases Bowman (2000).

Most of the literature reviewed here concerns direct personal communication between

ICU clinicians and family members. One issue of concern, in regard to the use of a

website to provide information how it would replace, complement or supplement the

traditional face-to-face modes of communication.

2.3.2 The Nature of communication between healthcare providers and

patients and their families

The findings from doctor/patient communication studies presented in the previous

section have resulted in a variety of recommendations about doctor behaviours that are

expected to result in improved quality of care. Communication in healthcare is the

primary process to gather and disseminate appropriate health information in order to

enhance the delivery of health care.

MacKinnon (1984) emphasises that effective communication is the ability to translate

information accurately and in a timely manner. Various studies identify ineffective

communication as the major barrier to achieving quality care in the health care system

(Bhasale et al. 1998, and Wilson et al. 1995). According to Buller & Buller (1987), it is

also evident that patients’ satisfaction with the medical treatment received is a major

31

factor that contributes to patients’ compliance. Patients’ satisfaction is largely

dependent on the physicians’ communications in the doctor-patient interaction.

Lloyd & Bor (2004) identify that family and friends as well as doctors can be prejudiced

against the patients in terms of how they contracted the illness, or their habits, such as

drinking or smoking. Illness or injuries caused by patients’ habits or behaviours results

in negative attitudes towards the patient as if he or she deserved it, like a punishment.

Likewise, the nature of the patient’s condition influences the belief about the illness and

helps determine the level of care and the timeframe.

In his research, Daingerfield (1993) studies the communication patterns of critical care

nurses. Finding that there are two common patterns: adult-adult, where information is

exchanged between adults, and parent-child, when an adult is providing education to a

child. In contrast, Turnbull (1992) finds that there are three modes of communication

between patients and doctors in hospital settings: active-passive, guidance-cooperation,

and mutual participation.

Recent studies in critical care settings indicate that nurses should adapt family nursing

practices with a comprehensive approach to their patient care. It is suggested that a

family-centred care approach shifted the health care providers’ perspective to

collaborative systems that recognize the vital role of family involvement in ensuring the

health care of the patient (Forsythe 1998; Webster 1999; Stewart et al 2003). Irlam

(2002) acknowledges families as experts in the care of their child, and the information

that they provided is important to clinical decision making.

Lloyd & Bor (2004) identify the need to assess the social support, views and beliefs, as

they influence the illness and treatment. Also, they identify the challenges of dealing

with the patient’s family. While some doctors feel that dealing with families is a

hindrance in their health care, others recognize the need for necessary skills for dealing

32

with families.

In health communication, physicians mainly ask questions; provide information and

explanations and emotional support (Onget al., 1995).

Furthermore, Lloyd & Bor (2004) advocate that the ability to communicate with

patients is essential for good medical care. On the other hand, occasionally medical staff

has to communicate with the patients’ families, which has a direct relevance to the

patients’ care.

There is a growing demand to provide care information in a written format; for

example, in a booklet or information sheet, including written instructions and diagrams,

as well as providing verbal instructions (Scott et al. 2001).

According to Christopherson and Pfeiffer (1980) and Johnson (1990) patients who are

provided with and have read written information pre-operatively can experience less

anxiety, shorter hospital stays and a quicker recovery.

The patient may be too overwhelmed emotionally to process more than a fraction of the

information, so supplementing verbal explanations with written materials affords

patients an opportunity to read and reflect on important information. The format can be

verbal, print, or audiovisual. The message must be delivered to patients in lay language.

Mirr (1991) finds that despite the fact that family members could repeat the information

given to them by medical staff, when asked what the information meant; it was obvious

that they did not comprehend it. This illustrates the importance of having

comprehensible written literature that people can take away and refer to at a later date.

In addition, Fries (1998), Johnson (1990) and Larson (1999) find that providing written

health information can potentially improve customer’s confidence to manage their care,

or the care of a family member, decreasing stress and anxiety and improving satisfaction

with the services provided in hospitals. The professional communication between

33

healthcare providers occurs mainly in writing, for record keeping and sharing of

information (Gartland 1998). The communication between patients and nurses includes

verbal communication and non-verbal nurse-patient communication (vocal qualities,

body movement and touch) (Oliver 1991). Although patients rely on nurses for

clarification of health information, the research indicates a lack of attention to providing

open and informative communication (Byrne & Heyman 1997).

Many studies about doctor-patient communication find a significant positive

relationship between doctors’ communication skills and patients’ satisfaction (Stewart

1995 and Lenvinson & Roter 1993).

Effective and efficient communication increases in diagnosis accuracy, resulting in

fewer malpractices and an overall increase of doctor-patient satisfaction. In order to be

able to study doctor-patient interaction and communication, it is necessary that it be

studied from two different viewpoints, so as to observe both the patient and doctor side

and avoid any biases, as the method through which bad news is delivered makes a

difference. It is proven to influence patient anxiety, depression, hope and decision-

making. The other important part is this: physicians do not have to be born with

excellent communication skills, but rather should learn it as they practice (Ruiz-Moral et

al. 2006).

Patients have always required a need for health information and in multiple cases come

to a health care provider with information from an array of sources, with the Internet

being the main source. The Internet has been a huge transformer of how people access

and retrieve information, especially in the area of health information. Therefore, all

types of online medical services and products need to be clearly determined along with

standards of professional online conduct and ethical guidelines for the Internet (Charles

&Lazarus 2000).

34

The changes in the nature of healthcare provider-patient interaction can influence

patients’ trust, according to Deloitte (2006). A large 80% of Internet users seek health

information with around 7% of users searching health information each day (fox S.

Online health search 2006; Pew Internet & American Life Project; 2006).

A study conducted by Bylund et al. (2007) aims to discover patients’ experiences of

talking to their doctors about Internet health information. It also focusing on how

talking about how the online health information received impacts the patient and health

care provider relationship. The changes in the nature of healthcare provider-patient

interactions can influence patients’ trust, according to Deloitte (2006). A large 770

participants report they had discussed Internet health information with a health care

provider within the past 12 months. Participants were to complete a 30-item survey

containing open-ended and close-ended questions about general feelings and behaviours

when discussing their health via email with their service provider. Following this, 11

follow up questions were asked about the participant’s personal encounter and

communication style with the provider.

Evidence shows that when medical providers validate a patient’s effort, it may result in

improving a patient’s satisfaction and reducing their concern. In addition, these

improvements occur when the provider agrees with the information the patient has

retrieved. In many cases, it is common for providers to disagree with the information

retained by the patient. The results obtained from the study show that when this does

occur, the provider is taking the information critically which leads to further improving

the patient’s overall satisfaction. This study revealed that the technological phenomenon

of the Internet has profoundly amended the ways patients aim to find health information

and as a result, discussions of providers and their patients regarding the health

information were retrieved.

35

Increasingly, available health information on the Internet is the main reason that

transforms the nature of communication among healthcare providers and patients

(Lewis 2000). Patients send emails to their doctors and use the Internet to seek health

advice in chat rooms advice rather than relying on clinicians for advice.

Various research approaches are undertaken to understand nurses' communication with

patients that include verbal and non-verbal communication. Verbal communication

methods include ethnographic studies using participants’ observations, recording

subjects' dialogue and applying conventional analysis (Jarrett & Payne, 1995). Other

non-verbal nurse-patient communication such as vocal qualities, body movement,

physical appearance, timing of conversation, personal space and touch, concentrates on

touch (Oliver, 1991). Lloyd & Bor (2004) state that the communication and information

exchange in clinical settings revealed several problems and barriers to effective

communication with families. Importantly, every family member’s ability to cope with

a relative’s illness varies. While some families are very supportive, others may be

repelled by the illness and not visit the patient at all. In addition, Lloyd & Bor (2004)

reveal that families and relatives enquiring about the patient’s condition can lead to

complications, such as, to find the truth, they may consult other medical staff who may

not be experienced or have the authority to provide the information, and decide not to

inform other relatives, including the patient, about the condition in an effort to avoid

hurting anyone; which limits confidentiality. Likewise, families’ reactions toward the

patient or illness can also cause problems; they may either ignore the situation, do

things that are not necessary, and/or apply wrong solutions to the problem.

In crisis situations in the emergency department, in which the patients and their families

usually are anxious, nurses claim that they do not have enough time to assess individual

patients, and during the process of caring there are many disruptions.

36

Byrne & Heyman (1997) state that as a result, assessing individual patients’ anxieties

with conflicting demands makes communication more difficult.

Furthermore, a number of studies explore how cultural factors influence nurse-patient

communication. Student nurses have difficulty communicating with the patients as they

lack the knowledge and authority to ask or answer patient’s questions.

Pauwels (1995) provides useful information about the nature of cultural contexts in

health communications in Australia, and he offers some practical and useful examples

of how to improve the communication with patients from different cultures in multi-

cultural countries like Australia.

Ohtaki et al.’s (2003) study was conducted to examine communication patterns of the

doctor-patient communication in the U.S.A. and Japan using a cross-sectional study

with a sample of 20-out-patient consultations from five physicians in the U.S.A. and 20-

out- patient consultation of four physicians in Japan, using the following variables:

a- Time spent in each phase of the encounter

b- Number of categorized speech acts

c- Distribution of questions types

d- Frequencies of back channel responses and interruptions.

The importance of this study stems from the fact that little literature is known about

variations in doctor-patient communication, in different countries. In addition, it

explored the clinical training for the patient-oriented communication skills; this is a

necessary part of medical education because it produces effective practitioners.

The main results of the study are:

a- U.S.A. physicians spent more time in treatment and follow-up talks (31%) and

social conversations (12%), whereas Japanese physicians have longer physical

examinations (28 %) and consideration conversations (15%).

37

b- The doctor- patient ratios of total speech acts are similar.

c- The Japanese physicians and patients use back channel responses and

interruptions more than those in the U.S.A.

In general, culture actually influences patterns of doctor-patient communication due to

several cultural differences between countries, awareness of these differences.

Similarities can be used to educate clinicians about the best approaches to patients from

particular cultural backgrounds, which benefits and can create optimal cross-cultural

communication in doctor-patient encounters; bearing in mind that variations may reflect

cultural differences, whereas the similarities may reflect professional specifics

stemming from the shared need to fill the information gap between physicians and

patients.

When patients and doctors from different cultural groups communicate, they may

experience many pressures compared to those working from the same cultural group.

This cross-cultural encounter is not only difficult for the patient, but it can also place

many demands and anxiety on the doctor (Eleftheriadou 2004). Language is the most

common communication breaks down in cross-cultural situations. Even if a patient is

familiar with the primary language of the particular country he or she is in, there may be

misunderstandings or confusions with not only medical terminology, but also with what

the doctor is trying to convey. This may, as a result, pressure the doctor patient-

relationship and create negative implications for the patient’s care.

In some cases, when an interpreter is not available, doctors treating patients with little

knowledge and understanding of English can present cards that have key words and

their translations in other languages in order to convey a message. In every medical

encounter it would be crucial to take into consideration the patient’s racial and cultural

difference and expectations, in order to be able to communicate effectively with the

38

patient. Doctors and medical staff should adopt a non-judgmental and understanding

nature towards patients’ personal beliefs, practices and rituals.

It is a possibility that the doctor may have a different cultural perspective and alternative

concept of health care to those of the patient. For instance, a patient may feel upset and

frustrated because their cultural background needs are not being taken into

consideration and as a result the patient may not comply with the doctor’s medical

treatments. Each culture has alternative views of acceptable forms of medical treatment

and health care, hence, the reason why it is essential to encourage consultations and

regular conversations in order to meet the individual needs of the patient until all

information is understood. It is always important that the medical staff dealing with the

patient feels comfortable and is able to discuss the patient’s concerns (Eleftheriadou

2004).

Another study by Schouten & Meeuwesen (2005) was conducted to gain more insight

into the effects of patients’ and doctors’ cultural/ethnic background in the medical

communication process. The main focus is on communicative behaviour by reviewing

observational studies on intercultural medical communication and also to include other

research methods such as surveys, focus groups and so on. The final findings of the

study are to be used as a design research model that can be used in future research on

this topic. The literature search produced (14) articles that examined the impact of

patient culture on doctor-patient communication, and, most studies were carried out in

the U.S.

Three studies assess the impact of intercultural doctor-patient communication on a

number of health-related outcomes, such as patient understanding, compliance and

satisfaction. For example, Harmsen (2003) finds that ethnic minority patients are

prescribed medication more often than white patients, irrespective of differences in

39

communication. In general, it is hard to reach definite results from doctor-patient

communication. The general findings from this study conclude that findings do suggest

considerable differences and difficulties in communication between doctors and

different ethnic backgrounds, and yet could not demonstrate a relationship with

difficulties in doctor-patient communication. Findings also showed that ethnic minority

patients suffer worse health-related outcomes, such as satisfaction and compliance, than

white patients.

The main conclusion of this study is that the extents of gaps in intercultural

communication and the relationship between cultural variations in medical

communication and health outcomes are still near unexplored topics in the research.

There is a need to classily which aspects of doctor-patient communication are universal

and which are culture-specific, as culture can add just one more dimension to an already

difficult communication situation. Physicians are not always good at detecting patient

distress during bad news delivery. Another important point is that the level and time of

distress is very different between the two (Lee, Back, Block, and. Stewart 2002).

Poor communication affects the delivery and quality of care outcomes (Brannon &

Bucher 1989). For example, inadequate referral communication causes inefficiencies

such as having other healthcare providers spend time and resources collecting the

missing information, duplicating existing data, and irritating patients and families with

repeated questions (Buller & Buller 1987). The patient may be too emotionally

overwhelmed to process more than a fraction of information, so supplementing verbal

explanations with written materials affords patients an opportunity to read and reflect on

important information. The format can be verbal, print, or audiovisual. The message

must be delivered to patients in lay language (Lee et al. 2002).

40

A study by Ruiz-Moral et al. (2006) explores an array of communication techniques and

behaviours that are adopted by specialty physicians and looks to the ways that their

patients interpret them. The results obtained through the achievement of this study

showed that most patients have a good or very good overall impression of all different

aspects of the encounter with the doctor. A high percentage 80% of patient’s is highly

satisfied with the clinical encounter. It was sighted that there is not a relationship found

between the patient’s satisfaction and age, gender or marital status.

Ruiz-Moral et al. (2006) find that doctors’ communication behaviours are noted to be

better with patients who are younger and have more education and patients who

attended surgery in urban areas rather than rural areas were more thoroughly satisfied.

In cases where the external observer is present, some items related directly to patient

satisfaction, such as the positive signs of affection when a doctor would greet the patient

by his / her first name, smiling, understanding patient expectations of how their illness

is affecting him/her. Less than one doctor out of every four allows the opportunity for

the patient to participate in any type of decision making at the surgery.

A study by Sheldon et al. (2006) aims to explore what the nurses defines difficult

communication as, with their patients using the grounded theory methodology with a

convenience sample. Recruitment for the first focus group came from a 220 bed

hospital.

In order to validate the findings of the six groups the researcher sent a follow- up

questionnaire with the 13 categories of difficult communication that were identified in

the focus group using a Likert type of scale.

All participants were women with a mean age of 47.6 years and were registered nurses.

The majority was staff nurses and the most common specialty was oncology followed

by rehabilitation.

41

The five main definitions of difficult communication as perceived by the participants

are:

1. Specific diagnoses and clinical situations

2. Patient’s and family’s emotions

3. Nurse’s emotions

4. Nurse’s coping emotions with difficult communication

5. The triangle of nurse-physician-patient communication

The descriptive results show that the three highest scores for difficult communication

are: nurse-physician-patient communication, angry patient or family, and working with

patients with metastasis cancer.

In general, nurses’ personal negative emotions in response to clinical situations make

communication with patients more difficult, and failure on the part of the nurses to

allow open communication and patient disclosure is likely to increase patient anxiety.

Therefore, educational programs should include basic communication skills with

didactic and role playing components. They also should include the beliefs, feelings and

attitudes of healthcare providers.

According to McGrath et al. (2007) the electronic medical record (EMR) helps to

improve the quality of healthcare; because it has been shown to be more legible than

paper records. However, we have to bear in mind the negative impact it may have on

doctor- patient communication.

A physician’s use of the EMR influences the physician’s nonverbal communication

with a patient. This was found during a medical interview by videotaping (50) internal

medical clinic encounters with six staff physicians at veteran’s hospitals in the south-

western part of the state. After reviewing the literature, the study identified the

42

following common general categories of signals that encompass nonverbal messages:

kinesis, vocalic, chromatics and artefacts.

Physicians used the EMR extensively and it appeared to be an integral part of the

interview. EMR use is influenced by nonverbal communication related to kinesics, and

it can produce noticeable differences in doctor- patient nonverbal communication.

Additionally, limited data are currently available regarding the nature of communication

problems associated by providing information through web-based information systems

in critical health settings.

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2.4 ONLINE HEALTH INFORMATION SERVICE

2.4.1 Introduction

This study has explored the nature of communication in crisis environments such as

Intensive Care Units (ICU), from the perspectives both of the public and of clinicians

who find communication with families of patients important but difficult. The study

aims to provide a greater understanding of how information technologies can be used to

resolve problems that arise with the ad-hoc, face-to-face communication that currently

occurs in this area.

This section discusses the applications of computers in health care and how they are

used in terms of clinicians and the public. This research focuses on Internet and web-

based health information and communication applied to health information such as

(ICCMU).

2.4.2 Internet Web-based Information systems

The literature about information and communication technology by Blanton & Balch

(1995) and Brennan (1996b) demonstrates the needs and requirements in the use of

information and communication technologies for the collaboration and sharing of

information within and across disciplines. The use of communication technologies in

collaboration and sharing of information across organizational boundaries is widely

recognized (Blanton & Balch 1995; and Brennan 1996b). Introduction of computerized

systems has minimized workloads and resolved some of the problems related to

information flows between nurses and doctors. Despite difficulty for some, to comply

with the system, which causes some degree of disruption in the flow of information,

hindering efficient and effective communication, communication technology has

become the norm in healthcare.

44

Langefors (1973) asserts that an information system is a technological means to collect,

store, treat and distribute information. Web based information systems have led to the

development of web-based communities also called virtual or digital communities, in

recent days.

The WWW today is the most reliable mean for distributing information and as with any

information system, WBIS are designed to manage very large sets of information and

offer specialized services such as graphically enhanced multimedia presentations of

information and navigations facilities. Although the graphical characteristics make the

system attractive, for WBIS to be effective it is important for the system to ensure its

relevance and its usefulness (Mekhjian et al. 2004).

WBIS are designed to manage very large sets of data and to offer specialized services.

A study by Holloway (2005) identifies a number of issues that should be discussed if

the disparities in ICT use are to be addressed.

1. In every metropolitan area in Australia there are individuals who do not adopt

ICT and lack access to a computer or the Internet. The metropolitan areas are

characterized by concentrations of households with lower levels of education,

English-language skills, employment and income, especially households in

South-western Sydney, such as Fairfield, Bankstown and Liverpool.

2. To overcome the digital divide it is not only necessary to address the supply-side

barriers; Demand-side barriers have to be removed as well. One strategy is to

provide public access to the Internet via public libraries. Also, it is necessary to

improve access to appropriate facilities in specifically targeted areas within the

cities, which are convenient: providing the necessary resources to do this,

devising training sessions that address language and cultural barriers, as well as

having adequate speed, technical support and infrastructure.

45

Internet usage is significantly growing across all sectors, primarily as an information

resource. Stuart Orr et al. (2001) investigate the IT usage in the Australia health care

system. The main purpose of this study is to examine the role and impact of IT in the

service industry, especially in the health care sector. Previous studies conducted by

shoal and Ng (1998) identified that Australian businesses are not utilizing IT as a

strategic tool to create and sustain organizational competitive advantage. This study

sample consists of senior and middle managers of the southern health care network

(SHCN) to determine how IT applies to and benefits the health care sector. It replicates

Sohal and Ng’s (1998) study of IT use in Australian businesses, specifically

investigating IT within a not-for-profit health service network, which includes the

following aspects: organizational level strategic issues, corporate strategy and IT

strategy, competitive advantage through IT and IT implementation issues.

In general, the role of IT within the SHCN provides a supporting infrastructure for users

rather than one being pivotal for organizational strategic advantage. SHCN managers

should be educated in the benefits of IT to ensure that greater value is placed on the

effective management of information as a strategic resource, which can be used to gain

competitive advantage within the health care industry through provisions of superior

quality service.

The main conclusion of this study is that IT does have an important role to play in

health care networks, so it supports Cummings and Worley’s (1997) study, which

concludes that organizations can use planned changes to solve problems, to learn from

experience and to improve performance and to influence future change. It must be

adopted by the SHCN, in order for IT to continue to provide an effective service to the

community.

46

The goal of Norum et al.’s (2003) survey is to clarify cancer patients and relative’s

experiences and suggestions on the implementation of ICT in Norway. The study

found the following:

1. Cancer patients and their relatives still report the hospital doctor

followed by nurses and friends, as the most important informants.

2. While almost two-thirds of patients and relatives have access to the

Internet, fewer (one-third) have searched the Internet for medical information,

and only one-fifth have discussed the information accessed with their doctor

and only one-tenth have visited a hospital website.

3. Internet access is correlated with young age. Almost two-thirds

suggested that e-mail, telephone help lines and wireless application protocol

communication should be included to support hospital-patient communication.

4. The majority of cancer patients and relatives having access to the

Internet recommend ICT, saying it helps in patient-hospital communications

and suggests that hospital websites, waiting time, treatment offers and addresses

are the top three topics of interest on hospital websites.

Web based information service also benefits the users by providing access to

information from various locations when it best suits their schedules. These

characteristics encourage the development of web-based health care communities

(Epstein and Olsen 2001).

Gustafson (1999) examines home access to a computerized support system for people

with HIV/AIDS, which provides information, decision support, and online discussion

groups with other users.

There is no uniform language for nurses and physicians in healthcare, which limits

accurate documentation and delivery of communication. Covel et al. (1985) report that

47

colleagues, either through face-to-face communication, emails and voice mails, meet

50% of the clinical information requests. Therefore, according to Coiera et al. (2000)

both technical and non-technical interventions need to be identified to improve

communication processes.

There are increasing numbers of people who communicate and interactive through the

Internet to gather and exchange information, experiences and find electronic emotional

support groups. A study by the Paw Internet and American Life Project finds that

patients with chronic illness access the Internet for medical information more than those

who do not have a chronic illness (Paw Internet 2005). Internet driven information use

has increased significantly today with new technology in medicine. The Internet has a

major impact in delivery for medical information going to the public (Brakeman 2000,

and Taylor 2000). Doctors and medical practitioners today constantly review the

medical literature, condemning inappropriate advice while supporting and using the

online systems as well. WBIS connects patients with healthcare providers by secure e-

mail or Internet-based video consultations.

In general, proper measurement of patient satisfaction (PS) is important for the long-

term viability of a healthcare organization. Previous studies show that a decrease in PS

increases the likelihood that patients will change their old providers for a new one. The

purpose of this study by Zabada et al (2001) is to show that information technology (IT)

can help monitor and improve PS, and to measure the dimension of measuring PS

through the following four instruments: 1st) the patient satisfaction questionnaire (PSQ);

2nd) satisfaction with physicians and primary care scale (SPPCS); 3rd) patient judgments

of hospital quality instruments (PJHQ); and the 4th) is service quality instruments

(SERVQUAL), as a generic instrument.; all of which enable us to develop a four-

category classification:

48

1. Interaction evaluation.

2. Competence evaluation.

3. Financial transaction evaluation.

4. Facilitating factor evaluation.

An information system (IS) can serve as a major data collection instrument (Furse et al.

1994), and any IS that is patient-oriented must be organized around patients in order to

allow for a systemic collection and treatments of information (Furse et al. 1994).

The more integrated patients are in the hospital’s IS, the more likely patients will rate

the hospital higher on most satisfaction dimensions, bearing in mind that the proper

design of an IS is a prerequisite.

Also, it is important to devise a system that would ideally gather patient’s feedback

before they leave the service encounter. Such a system ensures that information is

captured while it is fresh in the patient’s mind, and it also makes it possible to recover a

service failure if the problem is discovered.

In regards to the management of care, the clinical information system has a significant

impact on reducing cost and improving quality. The computerized systems help

eliminate and prevent medication error.

The clinical information system has clinical benefits such as better management of

clinical information, which facilitates more informed decision-making and better patient

care. In addition, clinical information systems can lower the cost of managing the health

organization, as clinical decisions generate a high cost (Anderson 1997).

According to Bagian (2001) the potential benefit of ICU’s use of WBIS for patients and

their relatives are:

1. Increasing their knowledge of their own medical condition and the factors

impacting on their health.

49

2. Creating positive change in patients' attitudes and behaviours regarding their

participation and control in health care.

3. Improving the relationships with patients and clinicians to gain efficiency when

patients can be better able to access information about them, including the state

of their own health and the treatment they are receiving.

Online medicine should be allowed, but with regulations. We have to remember that

patients rely upon online information to supplement existing relationships with their

physicians, not to replace it. Also, online medicine may be allowed when treatment is

provided over one-time interactions, such as a second opinion, but not psychotherapy.

Demiris (2005) discusses virtual communities (VC) for home care patients that can be

accessible to patients and their families with continual monitoring of data for decision-

making. Another example of VC conveyed through a holistic approach to form an

interdisciplinary “Telehospice” that was established to focus on dying patients in their

last stages (Demiris, 2005, p.180).

Lack of moderation and attacks such as a hacker or virus raises concerns for security.

On the other hand, marginalisation of patients has also been identified in rural health

care centres that do not have access to the Internet or the resources to participate in

VCs.

According to Grandinetti (2000), it is estimated that there are more than 70,000 health-

related web sites in 2000. Patients with greater access to appropriate medical

information are expected to result in better health outcomes, better use of health

systems, building stronger relationships between patients and doctors.

Millions around the world use emails today and its use is growing daily. Many doctors

use emails to communicate with their patients. Emails use has a potential to expand

significantly in the medical world with greater use of the facilities by the patients,

50

complementary visits to the doctors, and improved compliance and access to care.

This method of communication has clear risks. Internet communication in an

established patient-physician relationship is encompassed by existing mechanisms and

standards for accountability: state licensing standards and oversight, and liability laws.

All these are missing in new patient-physician relationships. One important point is the

absence of the personal communication and connection that occurs in a face-to-face

meeting (Miller & Derse 2002).

Many studies are conducted to assess the quality of web-based health information

(Wilson 2002; Webster & Williams 2004; Jadad & Gagliardi 2002; Kamel Boulos et al.

2001; Gilliam et al. 2003; Kim et al. 1999 and Eysenbach et al. 2002).

The Internet facilitates discussions and informal consultations and reduces barriers to

communication. Online discussion forms exist for health professionals to exchange

information and access medical findings. Likewise, web-based forums can have high

quality discussion, as most of the sites require registration or are moderated. However,

as many users as open online forums may not use it.

In addition, chat rooms facilitate real time conversations, such as yahoo messenger and

all other instant messaging software. Even though the users cannot be verified by their

identity, moderators or attendants who lead the discussion can remove inappropriate

users.

In the context of health care, a virtual community is defined as a social structure based

on modern telecommunication with a common goal that conducts health care activities

collectively. These activities include providing health care service, education, and

problem-solving, providing support and sharing knowledge (Demiris 2005).

Virtual communities can be formed with health care professionals only, or with patients

and their families, or be open to the whole general public. This improves the quality of

51

the health care system by encouraging accurate and legible communication among the

health system.

Klemm (1999, p. 247) identifies three different types of uses of web based health

groups:

1. Sharing of information

2. Encouragement and support

3. Sharing of opinions and experiences

As the users of virtual communities are all over the world, this raises many challenges.

These challenges include participation of health cares, licensing, and with decreasing

face-to-face consultations, deterioration of interpersonal relationships.

While the web-based VCs have the potential to reach rural, under resourced

communities, digital divide is inevitable where many communities may not have the

resources or information to set up the infrastructure to join the VCs and enjoy the

benefits of knowledge sharing (Demiris 2005).

Despite growing recognition of web-based communities, it has failed, as WBIS does not

consider grass-root activism and the constraints for citizens with the availability of

WBIS (Ridell 2005). Wearing (1998) also identifies limited access to WBIS as the most

common barrier for most people. Besides limited access, lack of basic skills is another

barrier for people to participate in web-based communities, which limits people from

using the information system effectively. There are information systems literacy

differences amongst age groups across various regions and cultures (Ridell 2005).

According to Huntington et al. (2004) some problems with online support groups are: - Inaccurate and misleading information, which gets corrected by users

- Waiting to receive a response for an enquiry

- Can get addictive and change people’s behaviour

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- Accessibility to who and when

- Computer literacy and language

Socio-demographic and geographic factors are no longer barriers to participate in

online support groups.

Greenberg et al. (1997) reveal that strong links between people who live locally and

share physical space guarantees higher security and caring and results in wellbeing.

Many people expect the technology to support the strong links. However, the different

cultures, beliefs and ways of living do not support the strong links among people living

close together.

The main barrier to misinterpretation of information is the language barrier, as the users

are all over the world, and they can acquire information from sites with unfamiliar

languages. As such it is argued that the code of conduct for online health communities

should be consisting across the world to ensure greater accountability.

In an effort to increase awareness of public health, web sites and the Internet

conveniently fulfil this purpose. Common online activities are comprised of email

consultation with medical staff, online consultation with a doctor and patients support

groups.

2.4.3 Interaction Design

According to Te’eni et al. (2007) the interaction process is the system, which involves

users and enters input, the output from the system and the entire interaction feeling of

the interface. As the system has a function and can be used efficiently, effectively and

satisfactorily, it is usable to the user. The purpose of the interactive design is to ensure

usability of the product, i.e. easily understood by the users, effective and enjoyable to

use. Designing an interactive product involves understanding the situation and how it

can be improved. Effective ways to identify the strengths and weaknesses when

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designing a system would be to compare existing good and bad design systems, which

will assist in creating a better understanding of the designing process, and then identify

improvement options. A good design is produced with the users in mind and makes the

systems enjoyable to use.

According to Dix et al. (2004), the design process begins with identifying the

requirement, which can be obtained through interviewing people, studying the

documents and materials used and direct observation. The findings are then analysed to

reveal the key issues and communication in designing the system. The design is then

evaluated for its usability, which involves using a prototype, and improvements to the

systems are identified.

Therefore, as Preece et al. (2002) emphasized when considering the usability of the

design it is important to consider when, where and who is going to use the system.

Secondly, it is also important to understand the activities people do when interacting

with the product. This helps determine the type of activities the systems needs to

support and optimise the users’ interactions with the system.

The challenge is designing a system for multiple users with variable capabilities.

However, identifying the needs of specific users will increase the system usability. On

the other hand, it is often possible for designers to assume that what is obvious to them

is not understood by all. Communicating with the users of the system will provide an in-

depth understanding of the organization’s functions, activities, and close observation

will help understand the whole process.

The success and growth in interactive designing systems is credited to the

interdisciplinary approach to better understand the dynamics of human needs. The need

for other disciplines in designing became apparent with increased awareness and the

extended use of the system by the larger community (Preece et al. 2002).

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Dix et al. (2004, p. 192) define design as 'achieving goals within constraints' where

goals understand the purpose and use of the design, while constraints identify the

resources and requirements to develop the product. Human computer interaction

requires understanding the capacity of the computer and human behaviour to produce

the system design. It is inevitable for humans to make mistakes, which emphasizes the

need for the system design to reduce occurrence of the mistakes. For instance, in

physical design it is important to understand the material, its failures and strengths.

Usually systems are designed without considering the users and human factors; rather

they are designed to perform the task from a technical perspective. Hence, the system

designs are not interactive and lack the ability to perform the task. This emphasizes the

need to incorporate usability and the purpose of the systems for the users in designing

an interactive information system. The key elements to consider in the interactive

systems include ease of use, effectiveness and enjoyment for users. Preece, Rogers and

Sharp (2002) define interactive systems design as producing an interactive product that

supports users in their daily lives. Therefore, the purpose of the interactive design is to:

1. Enhance effectiveness, efficiency and safety to use

2. Good utility for users in order to perform

3. Easy to learn, and user friendly so the users can remember how to use

4. Enjoyable, helpful, motivating and pleasurable

The four necessary requirements of the interactive designs include ability to identify

needs and requirements, develop alternative needs that can fulfil the needs for the

requirement, and build interactive versions of the design to communicate, assess and

evaluate designs. It is a non-linear process where the evaluation through the interactive

version and results are the feedback to make improvements. A clear understanding of

the health information system design that has maximum users’ satisfaction and better

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performance is recognized (Preece et al. 2002).

Hence, the design should be conceptualized based on a clear understanding of the

problem, i.e. what the systems are required to do. The conceptualization process

involves designers in contemplating how the design will assist the users to perform their

activities using their assumptions.

Furthermore, Preece et al. (2002) identify that the major challenge of the interactive

design are the design work and the communication of the design work. The systems

designs can be communicated with the clients through a written report, which creates

common terminology. Reporting using common terminologies can establish the

medium to communicate the systems design between the designers and clients. In

addition, user training can further improve user attitude, behaviour, and performance

using the design process to incorporate the improvement to the design.

2.4.4 Human-Computer interaction

Te’eni et al. (2007) define human computer interactions (HCI) as a discipline that

attempts to understand and establish how people interact with computers in an

organizational context. The key to quality HCI lies in the well-defined interaction

design that mimics the human computer engagement processes. Therefore, HCI aims to

understand how the human computer interface can be achieved through high quality

design that performs and is usable, but incorporates human elements such as the

physical and social experiences of the interaction.

HCI involves incorporating human use and keys factors in the design, evaluation and

implementation process of the interactive systems in order to create a useable interactive

computer system. The central element of HCI is to identify the usability needs and

improve the users’ interfaces of task-oriented applications in the work context (Chan

2001).

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In other words, it is a study of human factors and machine aspects in the interaction.

According to Smith (1997), the interactive design also requires an appropriate

interactive style based on the user’s knowledge and tasks. Factors that help determine

the interaction style are initiation, flexibility, option complexity, information load and

interaction styles may defer, as suited for individual users (Smith 1997).

According to Te’eni et al. (2007), the poor design results in poor usability and high loss

of the organizations from the systems as the customers abandon them. The U.S.A

Military produced design criteria to achieve the required performance, reliability of

personal computer combinations, minimizing skills, personnel requirements and design

standardization. Nielsen (1993 cited by Te’eni et al. 2007, p. 145) identifies usability

goals:

1. Time to learn how to use the system

2. Speed of performance

3. Rate of error made by users

4. User’s retention time of information presented

5. User’s satisfaction with the system

Key elements in HCI design are identifying and understanding all the users of the

systems. For instance, in an organization the call centre records all the incoming callers’

requests and queries that get sent to respective sections for action. The data from the call

centre may further be used to identify customer satisfaction and the numbers of

complaints, which help improve the product or services by the organization. As such

there are direct users of the system who receive the call and record the information and

indirect users who use the information from the system for organizational improvement.

It is easier to determine the direct users; however, the best way to identify the indirect

users would be to ask the people in the organization (Dix et al. 2004).

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Preece et al. (2002) further emphasise the significance in the degree of user

involvement; that full time involvement of users’ contribution may become less

valuable as they become more familiar with the system and if the project continues over

years the user may lose touch with the user’s groups. On the other hand, a part-time user

can be more effective in long-term phases and provide important development

information. However, the degree of involvement may vary in different situations and

circumstances, as appropriate. The major reason for not involving users is that it is time

consuming to manage the input and control involvement.

Preece et al. (2002) accentuate the need for a user-centred approach in development

where real users are the driving force in the development of the product. In addition, he

discussed the three key principles of interactive design as revealed by Gould and Lewis

(1985); firstly the early one focuses on users and tasks, empirical measurements that

record and measure user’s reactions from early development stages; and lastly, iterative

design, which involves user testing and improving the system. Iterative designing is

today a widely accepted practice.

2.5 SYSTEMS DYNAMICS MODELLING

2.5.1 Literature of Systems Thinking and System Dynamics

Von Bertalanffy (1968) commenced development on the General System Theory in the

1930s in response to the developing complexities of the scientific era. Systems thinking

has further developed the theory over the ensuing decades in view of the influence of

modern technologies within the computational, behavioural and social sciences.

Checkland (1981, p.4) defines systems thinking as ‘using systems ideas to try and

understand the world’s complexity’.

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A systems thinking is an approach for developing models to support our understanding

of events, patterns of behaviour resulting in the events, and the underlying structure

responsible for the patterns of behaviour (Senge 1990).

Systems thinking is purported to be highly useful for dealing with complex systems and

problems. There is a widely held view that systems thinking is more advanced than

other approaches in terms of dealing with complexity (Richmond 1993). According to

Doyle and Ford (1999, p. 411) ‘A mental model of a dynamic system is a relatively

enduring and accessible, but limited, internal conceptual representation of an external

system (historical, existing or projected) whose structure is analogous to the perceived

structure of that system’.

According to Lane (1994, p. 107) ‘Systems thinking reveals why a thing is required to

work in the way it does’.

Systems thinking involves:

1. Conceptualising that the thing to be understood is part of a large system

2. Understanding the large system

3. Explaining the behaviour of the system in terms of its role in that large system

(Lane1994).

‘We’ve grown up in a reality in which local perspectives enabled us to do just fine, we

Hitchins (2005) defines the systems thinking as it seeks enlightenment through the

creation and exploitation of open, interacting, nonlinear dynamic systems models of

problems, situations and phenomena have developed certain -habits of thought- which

make it difficult to learn in an interdependent reality’ (Richmond 1994, p. 213).

System Dynamics modelling is an analytical tool that was developed by Jay Forester in

the 1960s, which was used in his industrial dynamics research. Wolstenholme (1990)

notes that System Dynamics is a precise method for qualitative description and analysis

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of complex systems in terms of their processes, organisational boundaries and

strategies.

According to Leonard & Beer (1994), System Dynamics is a modelling and simulation

tool to investigate complex dynamic problems in terms of their stocks and flows and

feedback loops.

However, System Dynamics combines qualitative and quantities approaches to enhance

the understanding of a system and the interaction of its subsystems. The literature on

System Dynamics highlights its application to a wide range of dynamic health care

issues.

System Dynamics is a method to deal with such problems as those in which time is a

significant factor, and which involve the study of how a system can be defended against

the shocks that come upon it from the outside world (Coyle 1979). Coyle (1996) further

argues that System Dynamics deals with the time-dependent behaviour of managed

systems with the aim of describing the system and understanding, through qualitative

and quantitative approaches, how information feedback governs its behaviour, and

designing information feedback structures through modelling. System Dynamics is a

suitable tool for predicting trends based on different variables and their change patterns,

as it is useful in modelling effects on social systems over time (Kim & Senge 1994).

Coyle (2000, p. 277) states that ‘qualitative modelling can be useful in its own right and

that quantification may be unwise if it is pushed beyond reasonable limits’.

System Dynamics is an approach for modelling dynamic systems that aims to

understand the system’s structure and behaviour. That is the main advantage of SD

modelling, as it is an instrument for the development of policies that lead to continuous

improvements in system performance (Sterman 2000).

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According to Vhzquez et al. (1998, p. 21), ‘System modelling through System

Dynamics (SD) is a complex scientific and technological activity, for which an

epistemological and methodological analysis could suggest some new and interesting

perspectives both to practitioners and theorists of SD’.

According to Doyle (1997), the goal of most System Dynamics interventions based on

systems thinking is to change or improve mental models to improve the quality of

dynamic decisions.

According to Dyson & Chang (2005), SD modelling is used to represent such complex

multi-domain systems and analyse its behaviour through breaking down the complex

problems to smaller sub-models that are linked to construct the crucial elements of the

system.

According to Barlas (1996), the major steps used in a typical System Dynamics study

are:

1. Problem identification

2. Model conceptualization (construction of a conceptual model)

3. Model formulation (construction of a formal model)

4. Model analysis and validation

5. Policy analysis and design

6. Implementation

The System Dynamics approach provides a conceptual view of the complex dynamic

systems to give better understandings of the system’s behaviour, the interactions

between the different elements, and to predict system behaviour under different

conditions or policy decisions (Costanza & Gottlieb 1998).

A System Dynamics application begins with the definition of a problem. It then draws

in all major patterns of influence that together create the system that produces and

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perpetuates the problem. System Dynamics searches for the causes of system behaviour

that lies within the system, with events outside serving as triggers rather than causes.

The system boundaries in a SD model are typically broader than those of other systems

models. It describes dynamic patterns in terms of structural relationships between its

multiple positive and negative feedback loops and the level of stocks and rates flows of

its primary variables. Models using System Dynamics are nonlinear with multiple

feedback loops, which allow its use in complex situations where another may replace

one main factor over time (Leonard & Beer 1994).

Sterman (1994) notes that to learn and understand the complex systems, SD must

incorporate a variety of tools that can:

1. Clarify and formulate the complex issues

2. Elicit beliefs and knowledge

3. Construct maps of feedback structure from that beliefs and knowledge

In practice, researchers usually design their own process with embedded stages to

accomplish SD simulation modelling for specific purposes. For instance Wolstenholme

(1990) suggests a two-stage process where the emphasis is firstly on gathering

qualitative information then quantification.

Coyle (1996) identifies a five-stage approach for System Dynamics modelling process:

1. Problem Definition

2. Developing an Initial Diagram,

3. Conducting Qualitative Analysis.

4. Constructing a Simulation Model

5. Verification Ideas and Policy Design

The System Dynamics modelling process illustrates two modelling phases,

conceptualisation and formulation. In the conceptualisation phase there is an iterative

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design process moving from familiarisation to real world description. The formulation

phase iterates between real world description and policy experiments producing a series

of evolving models (Randers 1996).

The basic steps in SD modelling (Ford 1999):

STEP 1: Get acquainted with the system

STEP 2: Be specific about the dynamic problem

STEP 3: Construct the stock and flow diagram

STEP 4: Draw the causal loop diagram

STEP 5: Estimate the parameter values

STEP 6: Run the model to get a reference mode

STEP 7: Conduct sensitivity analysis

STEP 8: Test the impact of policies

Sterman (2000) emphasises that the idea of SD modelling is to build a model that can be

continually adjusted to reflect the real world. According to Lynne et al. 2004 SD

process provides good features to understand and solve the complex problem, yet we

would argue that in practice it is not exploited even though it would allow stakeholders

to gain a greater understanding of the problem.

According to Senge et al. (1994), systems thinking uses many of techniques that are

embedded in System Dynamics, such as feedback loops and stock flow modelling. As

Senge et al. (1994, p. 88) argue, it is ‘More powerful as a language, augmenting and

changing the ordinary ways we think and talk about complex’.

Causal loop diagrams provide a structure for seeing interrelationships rather than things,

for seeing patterns of change rather than static snapshots (Senge 1990). A stock and

flow diagram models a system as a network of variables represented as stocks and flows

interconnected by feedback loops. Causal loop diagrams represent closed loops linking

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resources and information and stock and flow diagrams representing levels of stocks

and rates of flows. These two diagrams and the use of suitable software to support

drawing these diagrams constitute the base on which System Dynamics is built (Pidd

2003).

According to Wolstenholme (1990), the vital idea in closed loop diagrams is that

information links knowledge about levels of stocks to rates of flows and specifies how

the rates of flow will change in the future to change the quantities of the resources in the

stocks.

A stock-flow diagram models the system as a network of variables represented as stocks

and flows consistent by feedback loops. Stocks illustrate the state of the system and

generate the information upon which decisions are based. The decisions then change the

rates of flow, which change the level of stocks by closing or opening the feedback loops

of the system.

Using specialised computer packages such as STELLA and ithink, SIMULINK and

MATLAB, POWERSIM or ANYLOGIC, VENSIM, one can also develop these two

kinds of models.

Richmond (2004) presents the argument for the possibility to evolve in the way we

think, communicate and learn. As a result, we will be better equipped to address the

challenges. He further acknowledged that it is however fundamental to address the

obstacles.

Using the STELLA software, Richmond (2004) illustrates the process of thinking,

communicating and learning. The thinking process involves constructing models that

are called, (mental models), which can be used to draw conclusions and help in decision

making. Mental models have various elements of reality that assist us to reason out and

make meaning out of our experiences with help in decision making.

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Richmond (2004) uses Stella software to illustrate the communication process, which is

comprised of the thinking activities, as the outputs of the thinking process are the inputs

of the communication process.

According to Richmond (2004), there are two types of learning:

* Self-reflective learning, which is from the thinking process

* Other-inspired learning from the communication process

The first type comes about when simulation outcomes are used to drive the process in

which the mental model’s content is changed, whereas the second type of learning

consists of the mental model, the simulation outcomes and/or the conclusions from the

simulation.

In particular, computer simulation is a technique used to imitate, on computers, systems

exhibiting complex, time-dependent behaviour. These systems cannot be studied by any

other reasonable means. Computer simulation is becoming the dominant technique in

many human activities. From the simulation, information is collected as if a real system

was being observed, and this simulation-generated data is used to estimate the measures

of performance of the system.

Why using modelling? (Banks 2000; Centeno 1996; Law and Kelton 2000, Pidd 1994)

1. New policies, operating procedures, decision rules, information flows,

organizational procedures, and so on can be explored without disrupting the

ongoing operations of the real system.

2. New hardware designs, physical layouts, transportation systems, and so on

can be tested without committing resources for their acquisition. Real

experiments may also turn out to be expensive, particularly if something

goes wrong.

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3. Hypotheses about how or why certain phenomena occur can be tested for

feasibility.

4. It supports experimentation with systems, with low cost and risk.

5. It provides an accurate estimate of the behaviour of the real system.

6. Insight can be obtained about the interaction of variables.

7. The modelling process raises important questions about the system and

subsystems behaviour.

8. Uses a user-friendly interface.

9. Allows for running of “what-if” questions to change some parameters of

system components without any impacts on the total system.

Eldabi et al. (2002) have identified many advantages of using SD modelling in health-

care systems. These authors state that SD offers good features to cope with both

problem understanding and problem solving. It also helps users to make a systematic

examination of their underlying assumptions.

The behaviour of a system as it evolves over time is studied by developing a SD model.

Once developed and validated, a model can be used to investigate a wide variety of

“what-if” questions about the real-world system. System Dynamics can also be used to

study systems in the design stage, before such systems are built. Thus, SD modelling

can be used both as an analysis tool for predicting the effect of changes to existing

systems, and as a design tool to predict the performance of new systems under varying

sets of circumstances.

Forester (1969) mentions that the elements of a system should be recognized:

1. Closed boundary around the system.

2. Feedback loops as the basic structural element within boundary.

3. Stock variable as accumulation within feedback loop.

4. Flow variable represent activity within feedback loop.

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There is an important issue in complex systems modelling process that involves the

decision makers during all project stages. The role of client involvement in

implementation of model results is recognized (Richardon 2000; Randers 1977;

Stenberg 1980). These approaches are now commonly referred to as 'group model

building'. Group model building is used in a wide variety of applied projects, as can be

seen in studies by Morecroft and Sterman (1994), Vennix et al. (1997).

Group model-building is used to involve the ‘client’ for a variety of reasons; to capture

knowledge, increase the chances of implementation of model results and enhance the

client learning process (Vennix 1999).

Vennix (1999, p. 379) states that ‘whichever way the project originates, in retrospect the

origination of a group-model building project frequently looks quite accidental’.

Stakeholders may be involved at different stages in the group model-building process.

At the least participatory level, a completed model may be used to demonstrate the

effects of alternative policies to stakeholders. A more participatory approach would

allow stakeholders to suggest scenarios to be tested. At the most participatory level

stakeholders can help develop the SD model that represents system structure.

Richardson (1996) identifies the eight problem areas of SD studies that are still yet to be

revised:

1. Understanding model behaviour

2. Accumulating wise practice

3. Advancing practice

4. Accumulating results

5. Making models accessible

6. Qualitative mapping and formal modelling

7. Widening the base

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8. Increasing confidence and validation

The main weaknesses identified with the System Dynamics approach are the problems

identification, evaluation, and difficulty in communicating the technique to potential

clients.

The value of quantification in some dynamics systems, Coyle (2000) argues that in

cases where the decision functions cannot represent the concepts, social issues and

sources of information that control the actual decisions, analysis should be constrained

to the qualitative level. To do otherwise is to create models ‘that are so meaningless as

to be valueless or, when practical decisions are involved, damaging’ (Coyle 2000, p.

233).

The review of SD modelling justifies its suitability for this research. The introduction of

systemic research illustrates the endeavours of SD modelling in understanding

complexities. The review about SD elements, purposes, processes, applications and

evolution provides the background information and rationale in choosing it as an

effective method in exploring such a complex, uncertain and dynamic issue as

communication in an ICU setting.

This study focuses on understanding the nature of communication and information flow

between healthcare providers and family members of critically ill patients using system

modelling. This section highlights progress and obstacles to date in applying SD

modelling to this current challenge in the healthcare sector. It also reports initial results

that have come from the related background investigations and early work with the SD

modelling.

2.5.2 Cases of System Modelling in Health Care

According to Fone et al. (2003), simulation modelling is widely used in military and

manufacturing sectors, to the extent that it sometimes represents a vital part of any

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planned project, SD modelling has only recently started to gain acceptance in the health

sector, despite its introduction over 30 years ago.

On the other hand, use of SD techniques is now increasing in the health-care system

where modelling is able to generate the information that enables decision-makers to

enhance their understanding to make better decisions to improve the quality of care that

is delivered, in order to satisfy the needs of patients and their families (De Mello et al.

1990).

Licker (1997) argues that the System Dynamics approach combines the strengths of

computers with modelling and simulation techniques to solve semi-structured or

unstructured problems that enable the decision makers to use suitable model structures

and analytical tools, together with their own judgment, to make decisions. This leads to

an extension of the capability of the decision making process, and improves its

effectiveness.

There are many applications of SD modelling in the health care system. Swisher &

Jacobson (2001), Barnes et al. (1997), Royston et al. (1999), Dangerfield (1999), Wright

(1987), Garcia et al. (1995) and Homer et al. (2004) illustrate some System Dynamics

models for the healthcare system by using different types SD models to address special

issues in healthcare. These authors state that System Dynamics offers features to cope

with both problem understanding and problem solving.

A wide variety of methods have been applied to model the accident and emergency

(A&) department, McGuire 1994; Brown et al. 1999; Lattice, Brails Ford, Turn bull

2004; Eldabi et al. 2000; Lane et al. 2000; Cooke et al. 2002; Brailsford et al 2004;

Connelly & Bair 2004; Lattimer et al. 2004; Braisford & Harper 2007). Simulation

models have been used for the analysis of chronic diseases such as diabetes, HIV/AIDS,

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sexually transmitted diseases, cancer, and heart disease (Dangerfield and Roberts 1996;

Lagergren 1998).

Wolstonhome (1999); Derrick et al. (2004); Kittell and Pallin (1992); Jun et al. (1999)

and Royston et al. (1999) use SD modelling and experimentation applications to study

unique issues in health care. These issues involve patient scheduling, public policy and

other hospital operational policies.

Wolstonholme (1999) uses a stock-flow approach to simulate patient’s flow through the

UK National health system, including primary, secondary health care and community

care. He concludes that the new intermediate care initiatives affect patients on waiting

lists more than other alternatives policies such as increasing hospital capacity. He

develops stock-flow simulation models to experiment on the effect of all alternative

polices by adjusting the values of flow in the model to provide the decision maker with

the best policy that addresses the patient flow in the UK health care system.

On the other hand, the study by Derrick et al addresses the consequences of the

reduction in hospital hours of trainee doctors both in their learning and in their

contribution to a provision of clinical services in the hospital.

A study by Kittell and Pallin (1992) at Mercy Hospital in Miami evaluates several

alternatives with the intent of getting more patients through the ER, while making more

efficient use of the department’s resources and still providing good quality services. It

shows that a 50% reduction of resources can be accomplished by implementing a fast-

track policy without risking the quality of service provided to its customers.

Another study by Jun et al. (1999) identifies the major areas in which simulation can

benefit patient flow:

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• It offers the opportunity to more effectively define and scope the range and nature of

potential benefits from a redesign proposal or innovation. This might include relevant

metrics and the means to measure them.

• It can provide deeper insights into the barriers and incentives to adoption (and hence

spread of good practice) that can subsequently be tested in field environments.

• It provides an environment where the final products can be ‘bench-tested’ with teams

of NHS staff prior to more formal release into service.

Royston et al. (1999) describe SD models for health care policies in The UK. These

health issues were modelled to evaluate the strategies for delivering health care services.

The group illustrates a range of projects that select the System Dynamics as an

appropriate tool for addressing a wide range of issues in health care services. These

issues involve disease screening and developing emergency health service systems. This

study reveals the opportunity for further development of the system for future use.

Likewise, Anderson et al. (2002) discuss the development of a computer simulation

model used to predict costs and patient outcomes on CABG surgery. This System

Dynamics model was developed using STELLA software, and data from Medicare

patients was used to construct and validate the model. Modelling analysis indicates that

the key factors that affect cost and outcomes are gender, age, number of operations

performed and patient’s response after operation. This model can also be used to

determine whether the costs and risks of CABG surgery are greater than the benefits for

patients with certain risk factors.

Brailsford et al. (2004) reveal the use of System Dynamics model to review the entire

emergency system, and on-demand systems. The conceptual map developed, based on

interviews of key individuals in health and social care, was used to construct a stock-

flow model. This model was used to indicate patient flow and constraints in the systems

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based on the existing activity data. The modelled results indicated various unfavourable

outcomes regarding growing demand for emergency service and the potential to

increase care options in the community.

These studies, together with the models of Hitchins (2003) on workflows, and

Richmond (2004) on the learning process, have strongly influenced the approach taken

in this research.

Both Hichins (2003), and De Mello & Gardner (1990), stress that SD is a powerful tool

for health-care management, because SD techniques introduce a new rigor and

discipline into management thinking on complex issues. These authors confirm that

using Stella greatly enhances the analytical power of management in health-care

systems.

2.6 ACTIVITY THEORY

2.6.1 An Overview of Activity Theory

The foundation of Activity Theory was laid down by Vygotsky and the cultural-

historical school of psychology founded by Vygotsky, Leontijex and Lurija (Rodriguez,

1998) in the 1920s and 30s in Russia. Activity Theory is based on a philosophical,

psychological and cross-disciplinary framework for the study of human practices as

their development progresses. Vygotsky initially aimed to discover the question of how

human consciousness is generated. In 1978 Vygotsky developed the triangle model

shown in Figure 2.1 to represents the main elements of human activity where, unlike

animal activity, Tools mediated the relationship between Subject and Object. This

challenged Pavlov’s well-known model of a direct relationship between stimulus and

response where human behaviour was thought to mimic that of animals.

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Figure 2.1: The Vygotskian Triangle

The third phase of the research involves an Activity Theory analysis of communication

in ICUs using activity as the unit of analysis as described in Chapter 3. Essentially,

Vygotsky (1978) defined human activity as a dialectic relationship between subject and

object, i.e. a person working at something. Vygotsky also believed that tools play a

mediating role in all human activities and mental processes which can only be

understood in terms of the tools and signs that mediate them. Tools expand our

possibility to manipulate and transform objects but also restrict what can be done within

the limitation of the tool, which, in turn, often stimulates improvements to the tool

(Verenikina & Gould 1998).

Kuutti (1999) describes Activity Theory as an approach to conceptualize relationships

between individuals, communities, technologies and activities that consider the tool to

be mediating human interaction with the world.

Engeström created a further enhanced model with additional elements to the Activity

Theory triangle shown in Figure 2.3 to enable an examination of Systems of Activity at

the macro level of the community. This expansion of the basic Vygotskian triangle aims

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to represent the social or collective elements in an Activity System, those being

Community, Rules and Division of labour.

Figure 2.2: The Structure of a Human Activity System (Engeström 1999)

Since most of human activities are collective, Engeström's model in Figure 2.2 includes

elements of collective activities and collaborative work, including community, rules and

division of labour. Community consists of all subjects involved in the same work and

work collectively. Rules are regarded as those that mediate the relationship between

subject and community that cover the conventions, regulations and social relations

within the community, which guide the activities and the behaviours in the system. In

addition, division of labour mediates the relationship between the community and the

objects.

Figure 2.3: Leontiev’s Model of Activity Levels (Verenikina and Gould 1998)

Action 1 – Goal 1 Action 2 – Goal 2 Action 3 – Goal 3

Activity Object (Motive)

Operation 1 Condition 1





Subject Object

CommunityDivision of

Labour Rules

Tools

Outcome

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Leontiev (1978), a student of Vygotsky, developed the Activity Theory Hierarchy,

which is represented in Figure 2.3, where the activity at the top is the principle unit of

analysis. Actions are a fundamental component of activities and consist of short-term

operations or tasks where goals are subordinated. Actions are a conscious representation

of a desired outcome, which consists of an intentional characteristic (what must be

done) as well as an operational characteristic (how it can be done).

Operations are ways in which actions are executed, and they correspond with goal

achievement. According to Leontiev (1978), an operation is something that is performed

by routine in order to complete an action in the current situation and condition. Leontiev

also accounts for the breakdown of activities into action and actions into operations

described as the hierarchical concept of activity, which is discussed later in the chapter.

Engeström (1999) indicates that the developments of the tools capacity might have been

mediated by language, observation and practice. Likewise, the practice would have

changed overtime due to individual people’s interactions with the tools and other people

in the setting, resulting in the transformation of the knowledge.

2.6.2 Activity Theory and Information Systems

Activity Theory has been applied in information systems (IS) and the related field of

Human Computer Interaction (HCI) and Knowledge Management (KM) researches for

more than a decade by various researchers (Kuutti 1991, Engeström 1987, Gould 1998,

Korpela et al. 2000, Bodker 1990, Kaptelinin 1996, Star 1996 and Suratmethakul &

Hasan 2004).

Activity Theory sees activity as an active, collective phenomenon, in the importance it

ascribes to collective learning. It provides an understanding of context in which

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computer-supported activities take place during design and evaluation, which is to

validate that well designed interface (Hasan, 1998).

Activity Theory is significant for information systems research. It demonstrates the

effects of tools and environment on human beings’ actions, reactions and behaviour in

work and in their relation with technology in general. This is remarkable, as it shows

through all technology the production of people’s experience and best effort. The theory

has a basic structure for application, but it is flexible in its nature and can be applied on

different researches in different fields. The theory has undergone stages of development

since the Russian psychologist Vygotsky, and is still dynamic and capable of more

adjustment and development. The current theory structure is efficient in researches

concerned with the application of usability tests on IS web sites, as it supports and

offers different means of analysis to the results that may be reached.

Hasan and Crawford (2003) indicate that, when the theory began with the Russian

psychologist Vygotsky, he indicated that human beings’ behaviours are affected by their

environment and background, and they are distinguished in their activities as a result of

the tools they use, and consider language as the most important tool. Interestingly,

Wartofsy (1979) classifies the tools that involve human activities into ones using

physical tools, thoughtful tools and surrounding tools, which all play a major role in the

human educational process that Vygotsky had already briefly indicated. Understanding

the importance of the tools that human beings are using enables the researcher to

explain the actions produced, or probably expect them. However, while it is true that

people grow and expand using these tools and enrich their experiences, they are able to

develop the tools they are using to conquer any restrictions they might face by the

limited abilities of these tools.

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2.6. 3 The Principals of Activity Theory

Activity Theory consists of a set of basic principles that determine the conceptual

system. These principles include the hierarchical structure of activity, object-

orientedness, internalization/externalization, tool medication and development.

2.6.3.1 Hierarchical structure of activity

Activities are comprised of actions with goals, and actions are comprised of operations

to meet the goal. With each of them, no matter whether they are an Activity, Action or

Operation, they are categorized in accordance with their purpose. In addition, activities

are considered as a collective Activity, and may consist of many subjects with different

roles that interact with each other to achieve their individual goals (Kuutti, 1991).

Leontiev (1981) used the model below to define activity hierarchy

Activity Motive

Action Goal

Operation Conditions

Figure 2.4: Leontiev (1981) Defined Activity Hierarchy as above

Leontiev illustrates in the hierarchy that activity is related to motives and purposes, and

actions are related to goals. However, actions become more organized with specific

goals and time limits. Actions can only be sensible when contributing to a certain

activity. As Leontiev (1981), defines, the activity is a system that has structure, its own

internal transitions and transformations, and its own development.

As Hasan and Crawford (2003) explain, the choice of the suitable activity depends

sometimes on the conditions. For instance, a company has different branches in

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different parts of the world. To apply a certain activity they always have to consider the

circumstances of that specific country. They will come up with different types of

activities to serve the same purpose. Since an activity is performed by several actions

and operations, the same activity can be performed by different sets of actions (Hasan

1998).

Kuutti (1999) also examines the Activity Theory and presents the three levels of

hierarchies in activities: activity, action and operation. Nardi’s (1996) examination of

the hierarchical structure in Activity Theory explicates that the unit of analysis is an

activity directed at an Object, which motivates the activity, giving it a precise direction.

This indicates that the activities are composed of goal-directed actions that must be

undertaken to fulfil the object. Therefore, Activity Theory holds that the constituents of

activity are not fixed, but can dynamically change as conditions change.

2.6.3.2 Object-orientedness

In the context of Activity Theory, object-orientation refers to the objective motive of an

activity (Christiansen, 1996). An activity is actually a dialectical relationship between

subject and object, ie who is doing what, and as Hasan (1998) indicates, the motive of

an activity is always objective, whether the activity is real or an idea. Indeed an activity

is always purposeful even if the subject is not fully aware of that purpose. There are two

kinds of objects, real, physical (material) objects and ideal (mental) objects, present in

the subject’s mind.

Bannon (1997) and Nardi (1996) both point out that the principle of object orientedness

states that humans live in a real world which is objective. Hence the things that

constitute this reality have the properties that are considered objective according to

natural sciences as well as socially and culturally defined properties.

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Kaptelinin (1992) reveals that whether the object is material or ideal it is of value as it

serves to fulfil some human needs. As every activity is directed toward the object and

defined by it as such, the activities are distinguished according to their object. Leont’ev

notes that the object only reveals itself in the process of doing. Hence, the object is

constantly under development and revealed in different forms for different participants

of an activity (Engeström 1990).

2.6.3.3 The use of tools

The crux of Activity Theory is that all human activities use tools distinguishing human

activity from animals. According to Wartofsky (1979), the tools that mediate human

activities can be:

* Primary Tools: artefacts, instruments, machines and computers, etc.

*Secondary Tools: Psychological Tools/Signs (language, sign, ideas and models),

or,

*Tertiary Tools: Psychological Tools - cultural systems, scientific fiction and

virtual realities, etc.

Since primary tools are physical, material tools they produce changes to the material

object, whereas the psychological tools influence the psyche and behaviour of subjects.

Tools determine the modes of operation and are developed considering cultural aspects.

As such, the culture-specific tools shapes the way people act.

2.6.3.4 Internalization and Externalization

It is one of the most important principles in Activity Theory as it differentiates between

internal and external activities. Internalization is a process, that transforms external

activities into internal ones, which facilitates the way for people to try potential

interactions in reality without having to perform actual manipulation with real objects;

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for example, mental stimulations, imaginations, considering alternative plans, etc.

(Bannon 1997). Mental processes refer to internal activities.

Externalization on the other hand is the opposite of internalisation where internal

activities are transformed into external activities. This process becomes handy in

situations where internalised actions need to be repaired or scaled. Therefore, Activity

Theory points out that those internal activities cannot be better understood if analysed in

isolation from external activities, as they are mutually dependant (Nardi 1996).

Kuutti (1996) acknowledges that activities have a dual nature as they have an internal

and external side. Vygotsky’s (1978) original model explicitly displays this nature by

the relationship between the subject and the object. Kuutti (1996) discusses the process

of internalization where the subject transforms the object using tools and at the same

time, the attributes of the object penetrate the subject and transform his/her mind.

Vygotsky (1978, pp. 55-57) describes this process of internalization as a series of

transformations.

Hasan (1998) explains that as activities are always related to motives, actions are always

related to goals. Hence, an activity consists of many actions and operations, but it is

more than the sum of these. The concept of internalisation as identified by Vygotsky

(1978) is the underlying mechanism for the origin of mental processes, all of which are

derived from external actions.

2.7 CHAPTER SUMMARY

This chapter reviews the background literature on which the work presented in the

following chapters is based. It provides published evidence for the changes to

communication due to the immense growth of ICT that will be used to underpin this

research motivated the challenges faced in the design of a particular Web-based

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Information Systems to support the communication between ICU staff and families of

patients in Intensive Care Units. Literature was presented to position the broader

research problem of this study which is identified as real and online communications

between professionals and the public. The literature concerns communication in general

and the particular case of communication between clinicians and patient families within

the context of hospital intensive care units as a valid instance of the wider research

problem. The Internet and online health communication literature is reviewed to support

the investigation of WBIS in the ICU context.

Finally this chapter presents the basics of System Dynamics and Activity Theory that

will be used to help in understanding and interpreting such complex situations.

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CHAPTER 3: THE RESEARCH DESIGN AND

METHODOLOGY

3.1 INTRODUCTION

The purpose of this chapter is to describe and justify the design and methodology used

for this research in solving the research problem and answering the research questions.

It presents:

• The justification and explication of the case of communication between

clinicians and patient families within the context of hospital intensive care units

as a valid instance of the wider research problem.

• A detailed description of the methodology adopted for data collection, reduction

and data analysis from the three sets of stakeholders of ICUs. This methodology

includes the use of interviews, Q-method and usability testing, as appropriate.

• An overview of the research approach using System Dynamics modelling based

on data collected, in order to holistically explore and visualize the emerging

concepts and the dynamic relationships among them.

• The use of Activity Theory to further explore these relationships as it provides a

means to examine the phenomenon of interest in a holistic and dynamic

framework that includes the community, the social context, the tools and most

importantly, the relationship between various less tangible concepts in the

environment.

This qualitative research approach is guided by the iterative model of Miles and

Huberman (1994), as shown in Figure 3.1. This model consists of four stages: data

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collection, then data reduction; after that, data display and the drawing, and verification

of conclusions. Particular innovations in this research are the use of Q-Method and

Usability Testing for data collection and reduction, reported in Chapter 4, the use of

System Dynamics models for data display, reported in Chapter 5, and the use of

Activity Theory in interpreting this model, reported in Chapter 6, to enrich the drawing

of conclusions.

Figure 3.1: The model of the Qualitative Research Process used in this research

following Miles and Huberman (1994)

The qualitative approach taken here is driven by the inability to quantitatively measure

many of the elements of interest in a meaningful way. The dissatisfaction with limited

findings that result from most existing studies in this area using quantitative data lead to

the demand for a qualitative approach to study these particular human phenomena

(Streubert & Carpenter, 1999).

Qualitative methods are often used in social science research studies, including those in

Information Systems and those that involve non-numerical examination and

Data Collection

Data Reduction

Data Display

Conclusions: Drawing / Verifying

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interpretation of observations to discover the underlying meaning and patterns of

relationships. Qualitative research is of advantage when it is suspected that the present

knowledge or theories are biased, and where little is known about the phenomenon.

Qualitative research gives emphasis to the processes and meanings that have not been

thoroughly studied or measured in terms of quantity, intensity or frequency.

A qualitative approach involves data collection through interviewing to gather

information that cannot be observed, and involves individuals’ perceptions, their

behaviours and attitudes. Therefore, qualitative research facilitates better understanding

about how people live and deal with their daily lives, which can provide an in-depth

understanding of the real world. The findings of qualitative research are used to build on

to existing theory and for further testing through quantitative methods. In this research a

qualitative approach to data collection and analysis is required to understand the needs

of three sets of stakeholders.

3.2 THE ICU AS A CRITICAL CASE OF THE WIDER RESEARCH

PROBLEM

As stated in Chapter 1, the research problem addressed in this thesis deals with the use

of innovative information systems to support communication between professionals and

the general public, particularly under crisis conditions. As discussed in Chapter 2, this

problem is routinely faced in the ICU where the professional clinicians need to

communication with members of the public, namely, families of patients who are

usually unable to engage in communication themselves, for the benefit of the patient as

well as their families.

This study deals with complex issues in the dynamic and high stress environment of

intensive care where medical information exchanges often take place under conditions

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of stress and are complex and dynamic. Conducting research in this area is therefore a

prime example of when it is necessary to take a multifaceted holistic approach that

integrates human aspects of the latest ICT tools and processes with the needs of all

stakeholder groups.

As shown in Chapter 2, the selection of the ICU as a suitable site for this research is

justified on several counts. Communication with families in intensive care setting is

complicated because the admission to ICU is often unexpected and the families are

often under emotional circumstances. In such crisis situations, families may not have

medical knowledge to understand the ICU environment. High levels of stress and

depression associated with the changes in patient medical conditions may affect the

communication with nurses and physicians. ICT support for ICU information makes

sense, as there is inadequate time available for clinicians to communicate with families,

so the direct interaction between clinician and family members in the intensive care unit

is limited. The complex medical information can be thoughtfully presented in the ICU

website content where there is a need for clear and direct communication. There are

now an increasing number of people who rely on the Internet to communicate and

interact in order to gather and exchange information.

The particular case from which data was gathered in this research concerns a division

established within a State Health Department, to provide centralized information

resources to the ICUs across the State. This takes the form of an online service to

facilitate communication between and among the state’s regional ICUs so that

information is shared with clinicians, patients, their families and the community. The

inspiration for this study is the need to evaluate the development and use of this Web

based Information Service in order to provide informed recommendations with regard to

its ongoing improvement. The data collection and analysis from the ICUs was

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undertaken as part of a long term action research investigation to assist the development

of the whole website, whereas the study presented here concentrates on only one aspect

of the website, the public part of the web-service for patients’ families. The research

reported here is an exploration of the communication issues between clinicians and

families of ICU patients as an instance of the broader problem of effective information

systems for professional public communication.

3.3 DATA COLLECTION AND ANALYSIS FROM ICU

STAKEHOLDERS

As stated in Chapter 1 the research presented in this thesis has been undertaken in

conjunction with a long-term study is involving a team of university researchers and a

central Coordination and Monitoring Unit for ICUs in the NSW State Health System.

This long-term study is looking at the attitudes of ICU staff to the whole web site most

of which provides information of a professional nature. This team consists of seven

academics and post-graduate students who are specialized in the evaluation of health

web-based information system.

As an associated component of this project, my thesis takes a broader look at the

information provided on the website for the general public and, in particular patients’

families. In regards to data collection I make it clear which data I use in my analysis

that was collected by the team and which was collected by me independently. I will

naturally describe the latter process in greater detail.

In my study, the main stakeholders are those involved in communication and

information flows between clinicians and members of the public in the State Hospital

ICUs and are:

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• Staff at the state level responsible for monitoring and co-ordinating ICUs

and for the planning, development and content of the Website;

• Administrative and healthcare staff in ICUs; and

• Families of patients in the ICU and the general public.

Suitable methods of data collection from each group are designed as follows:

3.3.1 State-based staff as owners and developers of the Website

As part of the project team working for more than a year on the long-term study of the

whole web site, I have gained a comprehensive understanding of the purpose and

rationale for the design of that section of the ICU web site which provides information

for patients’ families. In order to confirm and deepen this understanding as far as my

research concern, an in-depth and semi-structured interview was held with one manager

of the web site development group.

The taped-recorded interview started with an open question, where the manager asked

about the rationale and purpose of the current web-based information system. The

manager was also asked some supplementary questions about her views on the

communication between ICU staff and relatives of critically ill patients. Then specific

questions were asked in order to identify the purpose of the website and what it provides

for the users (clinicians and general public, patients and families). The interview lasted

about one hour. After this interview I compared notes of the content in the interview

with my previous knowledge of the website from the perspective of its owners and

developers. The entire data collection process provided a wealth of data for the ensuing

analysis and modelling.

There are a number of interview methods used in qualitative research to collate data,

which include face-to-face, structured, semi-structured and unstructured interviews. The

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reliability and validity of information gathered through interviews varies with the

interview method. Face-to-face interviews are the most common and effective methods

used by interviewers; they can be conducted individually or in groups. Respondents in

face-to-face interviews are carefully identified rather than randomly selected. In

contrast, a structured interview is a set of questions presented to respondents.

The structured interviews have a distinct purpose and are inflexible as they have a

limited number of responses, and respondents are required to provide answers for all the

questions, which may not be a true representation of their opinion (Steinar, 1996).

Semi-structured interviews start with a question followed by investigative questions to

identify the respondent’s subjective opinions, experiences or knowledge of the event.

Unstructured interviews are also seen as informal, as they do not involve a list of

questions. According to Seidman (1998), an unstructured interview is handy as a

preliminary study to gauge the responses on a particular issue.

3.3.2 ICU Administrators and Clinicians

The data from this set of stakeholders comes from a commissioned project to uncover

attitudes to the website within the ICUs themselves. This project involved a number of

researchers and used a Q methodology approach that facilitates the collection of

individuals’ thoughts about, and attitudes towards, the website as well as how they had

used it and intended to use it in the future. I would like to acknowledge the contribution

of these colleagues in gathering this part of the data used in the research. The results of

the extended Q-study of attitudes towards the website have been published by them

(Meloche & Mok 2005). I have taken the set of statements collected from ICU staff in

the first (concourse) stage of the Q-study and reanalysed it for my purpose.

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Q Methodology consists of procedures and a theoretical structure with the ability to

reveal communicative subjectivity, giving a voice to the understandings of participants.

Thus the intention is to let the people involved share their views and opinions, and to

further explore understandings of their experiences and expand on our knowledge of

their behaviours and attitudes (Brown 1986).

The Q technique is most valuable in situations that require aesthetic judgment, poetic

interpretation, perceptions of organizational role, political attitudes and subjective

opinions (Brown, 1986). Its effectiveness is evident in the simplicity of its use, whereby

anyone with basic statistical knowledge is able to use it and conduct studies on

individual experiences. Another advantage of Q Methodology is that it does not require

a large population to produce meaningful results. A Q sample of as few as 30

individuals can produce an accurate picture of the range of views on a topic (McKeown

& Thomas, 1990). The method involves allowing the participant to provide their own

views of the topic expressed in statement form and then sort out a range of information

systematically.

A review of the Q-methodology literature points to its potential use in health care

settings. Q methodology was developed to study individual attitudes and it has been

used to study communication patterns, political opinions, nurse-patient interaction, and

as tool for hospital strategic planning (Dennis 1986 and Barkley 1975). Q-methodology

consists of three procedures: the Concourse, the Q Sort and Q factor analysis.

The first procedure in a Q study is a concourse (a conversational brainstorming session)

on the topic, which includes the generating of statements (Meloche, 1999). The

concourse represents what people have to say about the topic under study, such that the

statements express all the possible views on the specific topic. The eliciting activity can

in practice vary from an actual discussion or interview to a review of a source

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(Stephenson, 1990). The collection of statements needs not occur in a single session, but

may transpire over time or amongst various groups. However, it is typically on the same

topic.

Q sort is the second procedure in the Q methodology to represent individuals’

perceptions and points of view towards the previous statements. The participants of the

sort are asked to make choices amongst the statements by sorting them, and all

statements are typically sorted in accordance with agreement/disagreement. +4 is high

agreement and –4 is high disagreement, then the scales between –4 and +4 reflect

shades/levels of agreement. The largest number of the statements is placed in the centre

and the least amount of statements at each extreme point (Meloche, 1999).

The following diagram is similar to the sample of the participant uses to record the

ranking of the statements.

Figure 3.2: Q-Sort triangles for ranking of the statements

Once the Q Sort is completed, the Q factor analysis is used for statistical analysis via

inter-correlations among the sorts into factors that reflect the views of groups of

participants. The result of a Q study is a description of the diversity of coherent opinions

on a particular topic, which are obtained as factors (Meloche 2003).

This Q study started with the concourse, which involves having the participants; provide

their thoughts (Meloche 1999) and views on, - in this case - “What should the ICCMU

Web based Information Service offer to its users community”.

Q1: Does the web information service help? Q2: How does it help? Q3: What other

services could it offer?

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The views held by ICU clinicians and other interested parties were sought about what

should the ICCMU Web based Information Service offer to its users community. Q

Methodology was employed to give a voice to users and thus allow them to contribute

to the improvement of the service.

The process started with a telephone meeting between the researchers and three

members of ICCMU Management where the first selection of statements was

developed. This was followed by physical visits to the various ICU units across NSW.

As NSW is a large state, this process involved a number of visits over a three-week

period.

To achieve this visits were done at urban, regional and remote locations to attain a

collections of views and ideas, in the form of statements, for four broad areas; Services,

Functions, Design and Outputs. In the first week, two major metropolitan ICUs were

visited, followed by a visit to an inter-western (city) suburb, and a rural ICU in the

centre of the State. The third week ICUs along the far north and central coast of NSW

were visited. In each meeting statements from previous meeting were given to the

participants to help include them is this way with the discussions that occurred

previously in the earlier venues

This method of building up the set of statements allowed the researchers to easily

engage with the ICU clinicians and served to prompt them with statements arising out of

their own context. This approach resulted in a large number of statements, reflecting

their views on the information services that could be provided by ICCMU.

In collecting statements from the ICU administrators and clinicians as well as debriefing

the participants in the usability tests, an innovative group decision support system, Zing,

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was used. Zing1 consists of a mix of hardware and software that allows for group

brainstorming and decision-making. Hardware enables multiple keyboards to control the

cursors on a PC or laptop on which the Zing software can be loaded and projected onto

a screen to be viewed by the participating group. Questions that facilitate the desired

group discussion session are loaded and each participant types in ideas and responses on

their own keyboard into their own anonymous window. When ready, they then fire up to

the public section above.

This has many advantages over other methods of qualitative data collection from groups

of stakeholders in a project. It is efficient in that all responses are collected in electronic

form and there is no typing on the part of the researchers. The wording is exactly as the

participants intended and all participants can enter data thoughtfully and

simultaneously, but with ideas from the general discussion. What is more, the system

that has wireless keyboards is engaging and stimulating for participants.

The strength and value of concourse phase of Q Methodology and the use of the Zing

tool to collect statement was apparent. The staff members in these ICU units are pressed

for time, and it is to their credit, that they participated in the research. It is also to the

credit of the methodology which almost immediately communicated about the

important; it places on the views of the participants.

The next stage of this research involved refining the collected statements to remove

duplicates and to check them for clarity and to examine them for possible categories to

which groups of statements may belong. Following the concourse and the refinement of

the statements the Q Sort technique was employed including the statements set, the

sorting instructions, and a grid sheet; all these things were distributed to the participants

1 http://www.anyzing.com/

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Other members of the project team undertook the Q-sort whereas my study only makes

use of the relevant categorised statements to illustrate the main views of this group of

stakeholders for the subsequent analysis and modelling.

3.3.3 Families of patients

For ethical and logistical considerations it was decided not to attempt to get primary

data from actual families of patients in ICUs. As the website is public and all members

of the public are potential users, it was decided to use an Activity Theory approach to

usability testing in a suitable laboratory. The Activity Theory view of usability testing

takes a realistic, down-to-earth approach, which identifies the purpose of the computer

system or website, and then tests it in a situation, which simulates that of the typical

real-life activities of the users. This approach involves surrogate users who are given

scenarios as realistic as possible to simulate what occurs in an ICU.

3.3.3.1 Usability Evaluation

Basic usability involves ease of use, easy to learn, error protection and efficiency of

performance (Nielsen 1993, Shackel 1986). Usability evaluation of computer-based

information systems is crucial, because it provides good feedback from the users to

assist the design team and the owner of the system in future enhancements. ISO (9241-

11) defines the four elements that are necessary to consider when creating a usable

system, as:

1. There are specified users of the system

2. The users have a set of specified goals.

3. The system should allow user goals to be met effectively in an efficient manner

and the users will be satisfied with the process or outcome.

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4. The system will be used in a particular context (e.g. within a physical location, a

business process).

Dumas and Redish (1993) state that usability testing has benefits for companies, and

captures the interest of designers, managers and end users. There are different categories

of usability evaluation methods, including expert review and participant testing. This

study uses the latter in a proper usability-testing laboratory.

Preece’s et al 2002describe how involving real users of the system in the design process

provides for better understanding of their needs and goals, resulting in more appropriate

and usable products. It is also important to consider people’s expectation and the

ownership of the product. Therefore, expectation management will ensure that the

users’ views and expectations are realistic, and this can be achieved by involving users

throughout the development process. Another solution to the problem of managing

expectation is through training, which allows people to use the product before it goes on

the market. The other reason for user involvement is ownership, which gives the users a

sense of ownership and receptivity to the product.

According to Rubin (1994) the sample size will depend on several factors:

1. The available resources

2. The availability of participants

3. The duration of the test session and the time required to prepare for the test.

Despite a perception that usability testing can be extensive and costly, there is evidence

that the best results come from testing no more than 5 users. Research suggests that 4 to

5 participants will yield 80-85% of the findings in a usability test, based on using the

Poisson binomial probability distribution (Nielsen and Landauer1993).

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The mathematical formula by Nielsen and Landauer (1993) represents the usability

problems in a usability test, where N equals participants, is:

N(1-(1-L)n)

Where N is the total number of problems in the design and L is the probability of an

average number of usability problems from a single participant.

Figure 3.3: Number of detected Usability Problems by number of tested subjects

Virzi (1992) investigated three areas to user interface testing through three experiments,

in order to study how the cost, time and complexity of traditional human factors testing

can be reduced. He used the Monte Carlo simulation technique and he concluded the

following:

1) 80% of usability problems would be found with 4 or 5 participants.

2) Additional participants would not add new information.

3) The first few participants are enough to detect the usability testing problems. This

result agrees with Nielson (1994a) and Lewis (1994), who find that involving additional

participants would result in fewer usability problems in the same usability test.

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Usability testing usually takes place in a specially designed laboratory. There are

different types of laboratory configuration and set up as shown in table 3.1 (Rubin

1994)

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Table 3.1: The Types of Usability Test Laboratory (Rubin 1994)

Description Advantages Disadvantages *Simple Single room: a quiet single room where the monitor is located 4 to 6 feet from the participant at about 45 degrees.

1 - Monitor the verbal and non-verbal actions of the participant. 2 -This position improves teamwork, especially during early phase exploratory tests. 3 - Presence of monitor is more encouraging to participant – not to feel alone and to think aloud.

1 - If the monitor is not mindful of personal actions, participant may pick them up as reactions to his/her work, which may distract him/her. 2- Limited room for observers.

*Electronic observation: observers physically separated in another room from test proceedings.

1- Advantages of single room settings. 2 - Freedom for observers to move around and discuss amongst themselves.

1 – Test monitor behaviour can negatively reflect on participant. 2 - Need of two conference rooms for up to a week.

*Classic Testing Laboratory: One room for testing and a second one for test monitor and observation.

1 - Unbiased data collecting. 2 - Test monitor and observers can freely talk and discuss among themselves. 3 - Room for many observers to attend.

1 - Participant may feel uncomfortable being alone surrounded by high- tech-equipment. 2 - Not effective for exploratory tests.

*Mobile Lab Testing equipments are carried to testing locations.

1 - No costs for location. 2 - Liberty to choose the available location. 3 - Less possible damage to equipment.

1 - Repetitive change of test environment. 2 - May affect delicate equipment in case there is a lot of testing.

3.3.3.2 The Usability Evaluation Process used in this study

The study presented in this thesis adopts an approach to usability testing that is based on

concepts from Activity Theory. The Activity Theory view of usability testing takes a

realistic and down-to-earth approach, which identifies the purpose of a business’s

computer system or web-site and tests it in a situation which simulates that of typical

real-life activities of the users. This approach suits the broad perspective of the study

and is practical as an Activity Theory Usability Laboratory (ATUL) is available to the

researcher.

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The research here focuses on the effectiveness of web-based health information services

in addressing the information needs of family members of critically ill patients, To

match this focus, the site chosen for usability evaluation is a section of a website for the

families of Intensive care Unit (ICU) patients provided by the NSW Health department,

established to provide centralized information resources to ICUs across the state. The

user group to be tested are families and friends of patients as members of the general

public. Real or surrogate users could be chosen as subjects for the tests.

The Activity Theory usability testing process is a follows:

Establishing the test goals: the first and very important step in conducting any website

evaluation is to establish the overall objectives of the evaluation. In this step, the

reasons for the evaluation and the proposed outcomes should be identified (Baca &

Cassidy, 1999 and Sears, 1995). The reasons for the evaluation of the current ICU

website and the expected outcomes of the evaluation are explained in Chapter 4.

Establish the system purpose: The clients and / owners are interviewed to determine

the business goals that the system is designed to achieve.

The aim of the particular part of the website to be tested is to facilitate the

communication between and among the state’s regional Intensive Care Units (ICUs)

and to share Information with Clinicians, patients’ families and the community. The

purpose is to also provide comparable resources for hospitals, health services and

practitioners in rural and urban areas by using online Web based services at state

hospitals.

Identify User Characteristics: The next step involves selecting and recruiting a sample

of reprehensive user participants, the users of the website being tested are families of

patients in an ICU. These can be anyone from expert Internet users to complete

computer novices. The one characteristic that they have in common is critical concern

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for the patient, the stress of which can either strengthen their resolve to find relevant

information from the site, or inhibit their ability to think clearly and act logically.

Most usability tests include two types of questionnaires:

*Participant profile questions (Pre-test questionnaire).

*Questions at the end of the session (Post-test questionnaire).

The pre-test and post-test questionnaires are a good tool to collect data and assess the

user’s overall satisfaction with the system when conducting a usability test.

The pre-test questions are background questions to identify the participants profile

before the test. After the test, the participants are given a brief questionnaire regarding

the usability of the web-based information service they have just evaluated (Rubin 1999

and Dumas & Redish 1993). There are many types of questions that can be asked in the

questionnaire – open-ended questions and closed questions.

The Scenarios According to Baillie, Benyon, Macaulay and Petersen (2003), a scenario describes a

particular task that a user needs to accomplish during the usability test. Carroll (2002)

defines scenarios as narrative descriptions of human activities which highlight the users’

goal and what are trying to o with the system.

The major benefits of the scenarios method is that reviewing and evaluating the system

is done in terms of realistic activities of usage. It enables the website developers to see

how well the system performs the assigned tasks by involving real participants to carry

out the required activities that the system is being designed to do. In addition, it reveals

the issues of usability, development, and implementation of the system. It also

recognizes the system significance, in processing and carrying out the users’ activities.

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A well-designed scenario for usability testing should give the participants enough

information to do the tasks; and its content and context should match with the

experience of the participants.

Conducting the Usability Test

In the usability laboratory, the scenario is explained and given to the subject who then

proceeds to carry it out. Simultaneous recording is made on videotape of the whole

room, the computer screen, the user’s facial expressions and hand movements and

audio, as prompted by the facilitator. The post-test interview is also recorded.

There are important issues that should be taken into consideration in this stage of

usability testing. First: using checklists to be sure that the test setting is ready for the test

to be conducted. Then the facilitator asks the participants profile questions, and if they

have any questions before starting the test. After that, the participants start reading the

scenarios and doing the tasks. The facilitator takes notes and should be neutral till the

participants finish all scenarios. Then he or she asks the post-test questions (Dumas and

Redish 1993).

Also, there are important issues when conducting a usability test. Make sure that the

users understand that it’s not them that are being evaluated; it is the system (Gordon

2000). The facilitator should make note of all possible feedback from the users during

the test.

This usability tests for this research were held in The Activity Theory Laboratory

(ATUL), a unit of the University of Wollongong. ATUL is set up for Human Computer

Interaction, Activity Theory and Knowledge Management and for practical usability

testing of systems using methods derived from that research. The principal objective of

ATUL is to conduct HCI research through formal usability testing and product

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evaluations in a realistic context, which provides for the analysis of group activities and

interaction, using an Activity Theory methodological approach.

Figure 3.4: ATUL Layout

Analyse the test records The final step in the usability testing process involves compiling and analysing the

findings and making recommendations for improvements to the design based on the

results.

According to Preece et al. (1994), the final report of the findings emphasises only

usability, identifying the concerns, and recommending some potential solutions. The

final report of findings may also include quotes, and users’ comments that are valuable

for analysing, in terms of the results of the usability test.

This researcher’s roles at this stage were: observer, data collector and data analyser of

the test results, as is described in Chapter 4.

3.4 THE PROCESS OF DEVELOPING THE SYSTEM DYNAMICS

MODEL

3.4.1 System Dynamics modelling and its suitability for this research

Following the data collection and analysis phase of the study as described above, the

subsequent phase of this study is that of SD modelling. This modelling phase of the

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study explores the communication issues by building a SD ‘stock and flow’ model in an

evolutionary fashion using STELLA software to represent and visualize information

flows. This display is able to increase the understanding of complex dynamic

phenomena within critical environments, such as those found in an ICU.

The foundation for the model is the results of the review of literature on the topic from

Chapter 2 together with data collected from the various stakeholders and its analysis as

described in Chapter 4. The use of Stella software, with its ‘stock and flow’ approach to

SD modelling, was used because these were available at the time and found to be

eminently suitable for the purpose of this study.

The SD model was developed in an evolutionary fashion in parallel with the literature

review as well as the collection and analysis of data from the three sets of stakeholders.

As will be shown later in the thesis, initially, the basic elements of the communication

process were set up in a simple conceptual model as separate stocks. This model was

then enhanced and integrated as new insights are gleaned from the literature and the

data analysis, and as feedback was received from other researchers and members of the

three stakeholder groups who were shown the latest version of the model.

The most challenging aspect of the modelling process would be the introduction of

dynamic elements to enable the model to be run as a simulation. As no quantitative data

are collected and very little of relevance is found in the literature, no attempts at

simulation are presented in this thesis.

The SD model was used to explore and display the issues in a dynamic and holistic way

in order to gain a greater understanding of the communication process and the role of

the website in this process. The models become a means of presenting this

understanding to all stakeholders, whose feedback informs further improvements to the

models, which should in turn inform practice.

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3.4.2 STELLA Software

While Stella has traditionally been used to represent stocks and flows of physical

materials, it can also be used for non-material entities such as information,

understanding and knowledge. Such entities are used in the researchers’ model, but it is

important to note that there is one significant difference where they are concerned.

When something physical, such as water, it flows and leaves one stock and moves to

another. When something like information flows it does not change the source in the

same way.

For example, if this researcher tells you some piece of information, I do not lose it when

you gain it. This has implications for stock-flow models in that, while separate stocks

have inflows and outflows the relationship between them is not a simple flow from one

to the other as one might intuitively think. Using Stella software is a computer-aided

way to effectively construct a good model of various aspects of the activities. Stella

provides an easy way to use a graphical interface for constructing dynamic models that

visualises and communicates how a system works through a stock flow diagram. In the

Stella language the stocks are nouns and are presented by rectangles, while flows in and

out of stocks are verbs that represent actions and activities. The other elements in the

Stella language are converters, represented as circles that are used to modify the verb

productivity and connectors that link converters to stocks, flow or other converters.

With this basic understanding the Stella model presented here should not be difficult to

interpret.

Stella is software for modelling and simulating dynamic systems approaches, developed

at High Performance Systems (ISEE Systems 2006). STELLA is a three-step method in

which equations that formulate simulations are automatically generated.

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In the first stage, called mapping, building block icons are used to build a qualitative

model; modellers first define stocks. Stocks represent anything that can accumulate or

change in number. Users construct links to variables that affect the size of the stocks.

These are usually direct inputs or outputs, modelled using flows. These flows can be

adjusted by converters using links or be affected by the size of stocks in a density-

dependent manner, and the converters contain equations that generate an output value

during each time-interval of a simulation. Converters often take in information and

transform it into use by another variable in the model.

This research treats the model as a conceptual tool to represent the integration of

dynamic elements of the focus of study and the potential relationships between them.

The second step in STELLA modelling would be to estimate values for the variable in

the model and quantify the relationships between them creating equations that are

needed to simulate a model. STELLA allows both linear and non-linear relationships to

be expressed. This would be followed by a third step, simulation of the model, to

generate output in tabular and graphical form to explore quantitative or qualitative

outcomes. Some speculation as to how this could be done is provided in Chapter 8

under future considerations.

Figure 3.5: Stock flow diagram

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Chapter 5 provides a detailed description and discussion about the model development

as a phase in the research with different versions based on the literature review, and data

collected from the three groups of WBIS stakeholders.

3.5 APPLYING ACTIVITY THEORY TO THE RESEARCH

PROBLEM

As advocated by the description of Activity Theory in Chapter 2, activity becomes the

unit analysis in the final phase of the research for a rich interpretation of the SD model

already developed. Here activity is directed by a subject towards an object and the way

tools mediate this relationship is used to explain what individuals or small groups of

people do in a variety of contexts when supported by socio-technical systems.

The SD model, while of great value to the understanding of information flows and their

impact in an ICU, is limited by the restrictions of this type of model based on stocks and

flows. For this research, the model was then qualitatively reinterpreted using concepts

and frameworks from Activity Theory in order to provide deeper insights into the

relationships within the system. As explained in Chapter 2, Activity Theory is

concerned with explaining and analysing human activity with a rich holistic

understanding of how people collaborate with the assistance of sophisticated tools in the

complex dynamic environments of modern organisations. The final stage of the

research, thus, uses Activity Theory to further explore the relationships between people,

tools, processes and elements of the ICU environment.

3.5.1 Step-by-Step use of Activity as the Unit of Analysis for Research

1. Identify the Core Activity of the System to be investigated

The analysis begins with the identification and explication of the central activity, or

sometimes the main two or three activities. Human activity is the primary concept and

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the unit of analysis employed in Activity Theory. Each activity is identified through the

dialectic relationship between subject and object where the object encompasses focus

and purpose, while the subject, a person or group engaged in the activity, incorporates

the various motives involved. Intended outcomes can be listed, but the researcher can

also look for unintended outcomes in retrospect.

Engeström (1987) uses activity as a unit of analysis in his research into developmental

work in organisations. His work has led the way in the use of Activity Theory in

organisational research by following the progress of a dominant activity, with any

interacting secondary activities, as an activity system. It is critical to understand the all

human activity takes place within the larger cultural-historical context through

interactions within the community where it is located. An activity is a form of doing,

oriented by an object, i.e. purpose, which transforms activity into outcomes and is

realized by a subject that undertakes the activity, such as a person or group engaged in

the activity. Objects can be material items or intangible in nature, such as a plan or an

idea.

According to Kuutti (1996), an activity is under continuous change, its development is

uneven and discontinuous, and the activity has a history of its own. Therefore, to

understand the current situations there is a need for the historical analysis of this

development.

2. Identify the Mediating Elements or Tools

Tools mediate the relationship between the subject and the object of all human activity

and this use of tools distinguishes us from other animal activity. According to

Wartofsky (1979), tools that mediate human activities can be primary (tangible, external

or physical), secondary (internal, semiotic or mental), or tertiary (schematics where

mind and culture act together such as environments or ecosystems).

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Tools are chosen to carry out an activity, but if the users are not able to use the tool to

achieve the task, the tools are either modified or further developed to achieve the

desired results (Hyland 1998). Activity Theory emphasises that “Tools” mediate Human

Activity in a broad sense as “Tools” are created and transformed during the

development of the activity itself and carry with them a particular cultural and historical

meaning from their development. As Nardi and Kaptelinin (1997) emphasise, tools have

value as they carry historical and cultural knowledge and the use of tools determine the

way people perform.

A WBIS is a complex tool which contains elements that are culturally appropriate and

effective. However, over time it will undergo transformations with respect to social

responsibility.

Internet-based tools are unique diffusers of cultural knowledge and are socially derived,

exemplifying human practices. Hasan (1998) stated that the social and cultural

properties of the environment are as important as the physical and biological ones.

Therefore, Activity Theory can be distinguished as physical objects and mental (ideal)

objects.

3. Identify the Activities that Support the Core Activity

As described in Hasan (2003b), following the work of Engeström (1999), Kuutti and

Virkunnen (1995), an activity system normally has one central activity, which is the

focal point of holistic investigation, surrounded by other activities with some link to the

central activity.

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Figure 3.6: Interrelated Activities in the Research of Engeström (1999)

Engeström (1999) has made particular, modern contributions to the theory and has

added a new approach for Activity Theory analysis which he calls Human Activity

Systems which reveals a link with systems thinking. He believes internal and external

tools cooperate together in the activity process. Internal tools are the absorption of

inherited culture by learning and training and external tools, which are the new creations

and inventions.

Each activity in an activity system is identified through the dialectic relationship

between subject and object where the object encompasses focus and purpose while the

subject, a person or group engaged in the activity, incorporates the various motives

involved.

According to Hasan & Gould (2001), as the activity is defined by its object it is evident

that each core activity can be considered as the centre of an activity system which is

then composed into a number of activities, each with their own objects.

Hasan (1998) uses Activity Theory as a framework of interrelated activities to present a

complex organisational situation. Hasan has applied Activity Theory to her analysis of

the executive information system (EIS) in an organisation. EIS is an information system

designed to support the strategic decision-making process of senior executives. Figure

3.6 shows the resulting activity system from this research where the EIS is a tool for the

core activity of informing the senior executives is related to two other activities:

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building the EIS and data collection for the EIS. The Activity Theory framework in this

case shows how these activities are interrelated.

Figure 3.7: Interrelated Activities in the Research of Hasan & Gould (2001)

Chapter 6 provides the detailed description of the application of Activity Theory to this

research problem. This process takes the System Dynamics model of information flows

in an ICU presented in Chapter 5, and develops an activity-based interpretation in light

of the central focus of the research, the activity of communication between the

professional clinicians and the families of patients, who are general members of the

public. The resulting activity system depicted uses the triangular representation of

Engeström, provides a deep understanding of the problem and contributes to the value

of the research outcomes.

3.6 CHAPTER SUMMARY

This chapter presents details of the qualitative research approach that is used for this

study.

The choice of the case of communication in an ICU setting is made and justified as

representing the main topic of the thesis. This chapter then provides a detailed

description of data collection methods from the three stakeholders in this study. In

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particular it analyses the importance of usability testing techniques to evaluate the

computer-based information systems.

The chapter goes on to provide a description of the System Dynamics model and its

suitability for visualising the data of the study. Finally, a framework from Activity

Theory is described which will be used to support this study in more depth from the

perspective of the activities of stakeholders.

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CHAPTER 4: DATA COLLECTION AND ANALYSIS

4.1 INTRODUCTION

The purpose of this chapter is to present the results of the first phase of the research

concerned with data collected on information flows and communication within ICUs in

New South Wales (NSW) State hospitals. This is related to the design and use of a

common Web-based Information Service (WBIS). The chapter presents the data

collected for each of the three sets of stakeholders, giving a broad comprehensive view

of the issue. As specified in Chapter 3, innovative and appropriate data collection

methods were used for each set of stakeholders giving data that is rich and contextual

being qualitative in nature. The researcher determined the context for the data collection

and analysis so that it suited the latter phases of the research: System Dynamics

modelling and its interpretation as an activity system. This chapter describes the

analysis and interpretation of the data, discussing, in detail, the different views of

communication within an ICU from the state-based staff and web-site developers, from

the staff in the ICU units and from the perspective of patients’ relatives.

4.2 THE RESEARCH CONTEXT

4.2.1 Design and use of a Particular WBIS for ICUs

In phase one of this study, data was gathered over a considerable time from different

groups of stakeholders in the WBIS of the Intensive Care Coordination Monitoring Unit

(ICCMU) of NSW Health. The study began when a team of researchers, including the

author of this thesis, were approached by the ICCMU management team for help with

their website. Background data was gathered from, documentation and several meetings

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with ICCMU developers and management team. I attended several research sessions

with my supervisors to fully understand the situation behind this thorough evaluation

and updating of the ICCMU website. This background context relevant to the research

is now presented.

Recognized by physicians during the 1960s and early 1970s, ICUs exist to provide

intensive care to patients with major injury, illness, or recovery after major surgery.

While some smaller rural and urban hospitals in NSW do not have this service, most of

the larger metropolitan hospitals have ICUs, and take seriously ill patients from smaller

units on a regular basis. To guide and co-ordinate ICU activities across the state, the

Intensive Care Coordination and Monitoring unit was set up as a division within the

NSW Health Department. ICCMU now has a clear focus of provision of Evidence

Based Practices, and a mandate to provide centralized information resources across the

state to promote communication for better health outcome in acute and intensive care. In

2003, the Australian Bureau of Statics published figures showing that communication

failures within the Health Care system contributed enormously to adverse clinical

events and outcomes, where communicational errors were found to be a leading cause

of in-hospital deaths, twice as high as those errors made because of inadequate clinical

skill. ICCMU Health Care WBIS was created in response to this, and is comprised of

three components, a closed web-site for NSW ICU clinicians and administrators, an

open-access website for the general public and the ICU Connect email list, which links

ICU practitioners worldwide. The WBIS aims, in particular, to increase communication

between disparate groups e.g. between regional and national ICUs as well as between

professional clinicians and the public. Traditionally most information exchanges

occurring within ICUs have been informal and not captured in formal computer

systems.

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The ICCMU team sees potential benefit in the use of the WBIS by clinicians to increase

their access to timely and reliable information. Patients and their relatives should also

benefit from increased availability of knowledge relevant to the patients’ conditions and

the factors impacting their health. This can create positive changes in their attitudes and

behaviours, and in self-monitoring to improve health care outcomes for patients. This

enables the patients – or more likely their families, to take a more active role in

maintaining their own wellbeing.

The current WBIS offers a great deal of information pertaining to intensive care

services in NSW for its users, e.g., customers, the general public and clinicians.

However, there is a substantial need for an appropriate review and analysis of the

current WBIS in terms of its functionality and design, content, security, and output to be

relevant to its purpose.

According to the ICCMU team functionality is one aspect of primary importance in the

website evaluation. Whatever the level of technology used, it must function well and

allow the user to progress logically through the site to the information needed. For

example, the ICCMU managers said that WBIS’ users need to be able to find useful and

vital information quickly through the practical use of search engines and help pages.

They do not want to turn off users with a slow WBIS connection. Furthermore, the

WBIS should be maintained so that have internal links are kept up to date, external links

relevant to the service are provided; the link to the site’s main page is clearly identified;

the navigation through the site is logical; the content is presented in an orderly manner,

and the overall design of the website promotes understanding of the content. WBIS’

artistic look and feel, as well as its usability enhances the site so it becomes more user-

friendly for its users. Add to that there is attractiveness to the site, which makes the

experience of use enjoyable.

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In the ICCMU site, content is as important as functionality in website evaluation. The

content includes text, image, web-based, and software downloadable types of

information. Information overload, such as too many images that slow down the web-

based download time, must be taken into consideration. The content also must address

each specific user, whether the general public or clinician users. Furthermore, content

should be informative, educational, of training material, and even contain references for

further information. In addition, web-based information must be easy and clear to read;

for example, no medical jargon for the general public. Information viewing must flow

so that users are able to pick up information easily.

Security is another important aspect of the ICCMU website, because much medical

information is of a sensitive nature and therefore must be kept confidential and

protected to endure user privacy. The security feature provides WBIS users with the

appropriate level of assurance that information cannot be hacked or changed in any

manner by unauthorized personnel. For example, to guard its users, WBIS has a

password protection. This results in a greater level of accuracy and integrity of content

on the WBIS.

The output aspect is closely related to how information is being downloaded, physically

viewed, printed, or stored; this is important to investigate. Users want to print out the

needed information in a clear fashion, so that print outs look good and fit on the

computer screen. Pages come with a link to a printer friendly version as the ICCMU

team envisaged that most users would prefer to read information in hardcopy.

As can be seen at the site2, the WBIS has a simple navigation design, which makes it

easy for users to access general information. The WBIS is divided into two major parts

of service: one part contains information that serves the community (visitors or general

2 http://www.Health.nsw.gov.au/iccmu

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public) and the other part contains information for clinicians. A simple click on the

index page can give general users access to either types of information. Beside links to

Community and Clinicians, ICU news and ICCMU reports, employment links, critical

care links; guideline links are added to the index page. There are seven (7) links located

at the top of the page that provide quick access to the following: 1) ‘Home’ goes to the

index page; 2) ‘Sitemap’ is a site map of the WBIS; 3) ‘Search’ allows users to discover

what they need through the search engine on the WBIS pages; 4) ‘Disclaimer’ shows a

disclaimer or supplier of the WBIS; 5) ‘ICU Archives’ goes to ICCMU news; 6) Admin

link and 7) Statistics.

To enhance familiarity for the users, all pages were designed in the same template. The

majority of the information is presented in a text format in order to allow shorter

loading time when links are selected.

On the Community (visitor or general public) information page, basic information,

facts, functions, or operations about the ICU and information of Intensive Care (ICU)

patients is presented. These pages are designed to be printer friendly. There are five (5)

links that belong to WBIS and another five (5) links that belong outside WBIS. The five

(5) links that belong to the WBIS are: 1) The ICU – goes to the page that explains

several ICU definitions, types, locations in NSW, the Intensive Care Unit Team and

Frequently Asked Questions about ICUs. 2) Patient Conditions goes to the page that

lists and explains all patient’s common conditions or critical illnesses by index from A

to Z. 3) Patient and Family – goes to the pages that provides answers to a range of

questions often asked by ICU visitors. 4) Patient Treatment in Intensive Care – goes to

the pages that provide simple explanations of everyday treatment, which are listed by

index, and tests where patients may experience an ICU. 5) ICU Equipment – goes to

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pages that list all equipment used, by index, in the ICU and describes each piece of

equipment.

On the Clinician information page, five (5) links contain a broad range of information

for intensive care clinicians. These links are: 1) ICU News – contains links to the

ICCMU News Letter, ICU Connect (state-wide list server), NSW Health Bulletin, NSW

Health-Intensive Care Taskforce, and Specialist Services. 2) Education in ICU –

contains links to the page that show seminars and conferences, educational package,

programs, and workshops. 3) ICU Employment – goes to the pages that list Internet and

Intranet critical care health jobs’ descriptions and employment opportunities in NSW. 4)

ICU Research and Quality – provides a description of future development; this link is

still under construction, however. 5) Critical Care Links – goes to the pages that link to

a range of health and critical care related websites.

On first inspection it was clear to the researcher that the current WBIS contains a wealth

of medical or intensive care information supplied in order to increase knowledge, and is

a good resource for those working in related fields. However, it is also clear that the

overall function of WBIS is mainly based on linking from page to page. Since users

have to go through all the links, finding specific information is slow as a result. Though

first impressions were that its design is fine, adding more functions and making it an

interactive site could improve the web-based information system. This would need

careful investigation to get it right.

4.2.2 Intensive Care Units

Intensive Care Units are categorised nationally into five different types and levels

depicted in Table (4.1). These are defined according to three main criteria: the nature of

the facility, the care process and the clinical standards and staffing requirements. All

levels and types of ICUs must be separate and be self-contained facilities in hospitals

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and, for clinical standards and staffing requirements, substantially conform to relevant

guidelines of the Australian Council on Healthcare Standards. Table 4.2 lists all

Intensive Care Units in NSW with the level at which they are registered.

Table 4.1: Types of ICUs

Adult ICU 3

Adult ICU 2

Adult ICU 1

Paediatric ICU

Neonatal ICU 3

Provides a complex multi-system life support referral centre of intensive care service with backup laboratory and clinical service facilities and mechanical ventilation, extracorporeal renal support services and invasive cardiovascular monitoring for an indefinite period.

Provides a complex, multi-system life support and provide mechanical ventilation, extracorporeal renal support services and invasive cardiovascular monitoring for a longer period.

Provides for basic multi-system life support and provide mechanical ventilation and simple invasive cardiovascular monitoring for a period of at least several hours.

Provides for basic multi-system life support, tertiary referral for children needing intensive care, backup laboratory and clinical service facilities to support the tertiary role that provides mechanical ventilation, extracorporeal renal support services and invasive cardiovascular monitoring for an indefinite period for infants and children.

Provides complex, multi-system life support for an indefinite period and provides mechanical ventilation and invasive cardiovascular monitoring.

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Table 4.2: Registered Intensive Care Units in NSW

Intensive Care Unit Level 3



Royal Newcastle Hospital Canterbury District Hospital Auburn District Hospital Griffith Base Hospital Maitland Hospital Belmont Hospital Shellharbour Hospital Armidale and New England Hospital Grafton Health Service - Grafton Base Camden Hospital Bowral and District Hospital Kurri Kurri District - Hospital unit Bulli Hospital Macksville & District Hospital Ballina District Hospital Casino District Hospital Maclean District Hospital Murwillumbah District Hospital Blue Mountains DHS - Katoomba Hospital

Manly District Hospital Mona Vale & District Hospital Ryde Hospital Fairfield Hospital Campbelltown Hospital Mount Druitt Hospital Albury Base Hospital and Nursing Home Wagga Wagga Base Hospital Dubbo Base Hospital Coffs Harbour & District Hospital Manning River Base Hospital Orange Base Hospital Tamworth Base Hospital Broken Hill Base Hospital Shoalhaven and District Hospital Bathurst Base Hospital Tweed Heads District Hospital Goulburn Base Hospital Kempsey Hospital

Gosford District Hospital Bankstown/Lidcombe HS Wollongong Hospital Newcastle Mater Misreicordiae Hospital Hornsby & Ku-Ring-Gai Hospital Sutherland Hospital Blacktown Hospital

Source: National Health Data Dictionary item “Intensive Care Unit”.

http://www.Health.nsw.gov.au

Data was collected from three sets of stakeholders:

• The State-based staff by interview;

• The ICU staff by a Q-study;

• Families of patients through usability tests with surrogate users.

The following three sections present the analysis of the three sets of data collected.

http://www.health.nsw.gov.au/�

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4.3 THE VIEW FROM THE STATE-BASED STAFF AND WEB-

SITE DEVELOPERS

A comprehensive understanding of the purpose and rationale for the design of the ICU

web site from the perspective of the owners and developers was gained by the whole

research team working with ICCMU. However, as described in Chapter 3, I held a one-

on-one interview with a representative of the ICCMU staff responsible for oversight of

all state ICUs in order to confirm and deepen this understanding of the WBIS as far as

my research is concern. A summary of the responses of the interviewee is now

presented, which includes a general summary and some significant answers to specific

questions.

Since information needs are the most important need for families of critically ill

patients, they should have access to information to make decisions about the patient,

who is often unable to make decisions by him or herself. The main objectives of this

WBIS are acting as an intensive care services resource for the state, monitoring

intensive care service provision, resources, utilization and activity, enhancing consumer

understanding of intensive care and advancing partnerships with its stakeholders.

There are legal and medical issues involved like illegal medical issues. So it is vital to

give good information, and the web site aims to do this for a community of intensive

care units. According to the interviewee in respect to the communication between the

healthcare team (ICU) and families, the web site provides general information. It was

never intended to replace personal communication, but it was designed to help to

provide more understanding for family members who are in such shock and stress that

they can’t absorb information as well as normal.

Q: To what extent will it replace personal communication in the future?

She answered:

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No, never. The verbal communication is essential because ICU staff need to establish relations with families. Our information is simple and general needs more explanations from ICU staff. Personal communication is vital for humans need so I will never encourage that.

When they need more explanation, sometimes the best way to give information is

through a written form rather than a verbal form. This can also save the valuable time of

nurses who often have to explain the same issue multiple times to different family

members, or even to one person who is stressed and confused.

Q: Do you expect that families will absorb information from ICCMU better than other sources?

A: Yes. That is my hope to faster communication in ICU environment. And information will be understood in written form better.

This service is unable to provide updated information about certain cases, so families

may not be able to communicate with hospitals through this service to gain access to

their patients’ medical conditions.

Q: How can families follow-up their patient’s medical conditions through the ICCMU and contact with the ICU team? They cannot. There is no plan in the future from ICCMU. But within the NSW health department there are hospitals that have electronically access to patient’s medical record. But for our site it is just as electronically sources and provides informational service but we have a big dream to achieve more for families and ICU.

It is readily apparent that substantial effort has gone into developing the content of the

web site and ensuring the quality and suitability of its presentation. It contains a

measured amount of authoritative, basic ICU knowledge in language that is

understandable by the non-professional. The web page uses a consistence minimalist

design that is appropriate for its purpose and use.

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Considerable effort has gone into the translation of much of the information into the

native languages of the major immigrant communities in the state.

An interpreter is used in certain situation, for example when the medical condition of a patient become critical and a decision should be made. But in daily communication there is no need for him, they may ask anybody in his family if they can speak and talk English well to talk with him about the medical condition for the patient then he can tell other relatives in their language.

Anticipated modes of use are on a computer in the waiting room, printed off in

conjunction with verbal communication, or the family is advised to lookup information

on the website at home.

The website director confirmed the importance of the electronic website in terms of

improving and developing the process of passing on ICU information to all stakeholders

easily and effectively. This means more improvement to the performance of the health

sector in general, and in particular, the ICU in NSW, Australia.

This website is still recent and needs continuous updating and upgrading to continue

facilitating effective services of communication between ICU workers and concerned

public, targeting the improvement of the health sector quality in the general provision of

services. Actually, it is part of the vision that the health sector benefit from technology

by establishing a website to provide important and detailed information about ICUs for

public access, facilitating the communication between the patients' families and the

workers in ICUs. Good communication is effective in improving the performance of the

ICU team, resulting in more satisfaction from the patients' families. The website enables

them to obtain sufficient and accurate information about their relatives in a simple

language. Thus, using the website is also effective in reducing the state of fear and

stress for families. At the same time, that the information available is in a valuable

database enables both the families and workers to share information on a state level.

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On the other hand and despite the benefits the website provides, it still needs improving

and continuous upgrading to sustain the satisfaction of users. It may also be important to

make the web site interactive and dynamic although this raises technical, usability and

legal concerns.

4.4 THE VIEW FROM STAFF IN ICU UNITS

As described in Chapter 3, a wide range of data was collected using Q-Methodology as

part of the wider study conducted by the whole research team including myself.

The concourse of the Q study, where a wide range of subjective statements are collected

from participants, was conducted through visits to 8 different ICUs, across the state.

Twenty-six participants, clinicians and administrators in eight hospitals contributed to

the statements collected, regarding three main questions concerning their

communication with patients’ families.

Q1: Does the web information service help? Q2: How does it help? Q3: What other

services could it offer?

The large number of statements is gathered by the concourse on each of the three

questions. While the complete Q method process was followed in the research, only the

statements collected in the concourse were used by me in the model development as the

results of the sorts were not available in time and would not have added significantly to

the model.

In general, the respondents considered that, although it is quite new, the website seems

to be an important source of information for families in specific areas. They agreed that

it would save their time if they could download information from this web site and give

it to patient’s relatives.

After the concourse, the collected statements were analysed and refined for the sorting

procedure, which, unlike the concourse, was done by individual participants.

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After my review of all statements and the thinking ICU staff as expressed in the

concourse, it was found that they saw the main WBIS role is to promote synergy

amongst ICU clinicians. They consider it important to build a “knowledge” base of

information, and to make it a 1-stop shop for clinicians and consumers of WBIS

services. They also recognised the importance of communication between clinicians and

the public, in order to help relatives of patients to develop realistic expectations about

the outcomes.

The statements show that the WBIS has the potential to promote synergy amongst ICU

clinicians and support ICU work to nurses and ICU staff, who consider it important that

it be a venue for critical and positive feedback.

Sample of statements collected from ICU staff

This research concentrated on ICU workers' feedback about how useful the website is in

improving the communication and exchanging of information between ICU workers and

ICU patients' families.

Through analysing the data obtained from ICU workers, it was found that their main

interest was in the availability of useful information about conferences, education and

positions vacant in ICUs in NSW.

Increase communication amongst Area Health Units 1 Stop Shop for clinicians and consumers of ICCMU services Coordinate research activities Promote ICU to nurses

Venue for nurses for information about ICU work and conditions Venue for practice guidelines Venue for a regional group network for regional events / news etc... Provide continuing education programs

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The most significant feedback on the public section of the WBIS received from all the

ICUs visited was that, as far as they knew, families of critical ill patients didn’t use the

web site, and it is not yet used by them at this time to help with communication with

families. However, they could see its potential. They suggested that it could help in

providing general information such as accommodation, visiting hours, other hospitals

services and access to hospitals’ web sites. The ICU staff suggested that it might be

used more if the web had visual information, especially for those who are illiterate; even

video clips would be helpful. Through the analysis of the statements offered by the

nurses working in the ICU, we concluded that they view the communication with

families as important. However, they face many obstacles to communicate in such crisis

situations where families may not have the medical knowledge to understand ICU

environment. The high levels of stress and depression associated with changes in the

patient’s medical conditions may affect the communication with nurses and physicians.

The studied group of nurses reported that the output of WBIS should decrease the

distress of relatives and provide image-based answers for relatives’ questions.

Current WBIS delivers ease and understandable information to family members who

participate in medical decisions and improve the general knowledge about the ICU

operation and vocabulary.

Provide available of information about ICUs - Level 4, Staffing information Provide lay descriptions and images of ICU services To provide all the background information Information about changes in the service for the end users - a what’s new Use the site to inform patient who are being transferred – about the place where they are going: complete phone numbers for patients & visiting hours etc…) To be a memory aid with reference information available Show facilities available in each hospital Raise the level of understanding about ICCMU for the relatives of

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They stress the importance of fulfilling the patients' families' need for information and

the importance of communicating with them. For these reasons, this web site is actually

a good resource for providing useful simplified information enabling families to better

understand the nature of ICUs. However, this website does not concentrate on

multiculturalism in Australia. Only a small part of the information on the website is

translated into a number of languages.

Also, the web site contains a huge amount of information that is not supported with

photos. Photographs could be very helpful in extending a clearer sense of reality to the

information and may reveal more assurance and closeness to the areas where patients

are in the ICU. The most important criteria the web site lacks are the service of

discussion and interactive communication. As a result, it doesn't really provide updated

information about the patients' conditions in ICUs.

4.5 THE VIEW OF PATIENTS’ RELATIVES

As described in Chapter 3, the website was evaluated from the end-user perspective, e.g.

families of critical care patients, using the activity-based usability testing method. This

approach involves surrogate users who are given three different scenarios as realistic as

possible to simulate what occurs in an ICU. As described in Chapter 3, the literature

shows that four to five tests using multiple scenarios are sufficient to detect the main

usability problems so that five tests using ten subjects and three scenarios were used

here. As previously mentioned, it takes five users to cover eighty percent of high-level

Improve information access for relatives Sections on services for relatives -financial services, emotional counseling etc To provide relatives with supportive information for their experience

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usability problems (Nielsen 2000). The Activity Theory Usability Testing procedure

described in Section 3.3.3.2 of the previous chapter was followed as is now described.

Establish Test Goals and System Purpose: The expected outcomes of the evaluation

of the public section ICU website are as follows: The specific focus from this usability

testing is to evaluate an evolving online health information service in the context of an

ICU where the patient is not able to communicate; so, clinicians must inform families

and friend on their behalf. Here there is communication between families and health

care professionals in the stressful situation in the ICU. The general goal for this project

is to present a more realistic perspective of web-based health information as one of the

communication channels between professionals and the public. The particular case used

here highlights the role associated the Internet in this communication and to explore

how that will affect health information received.

This research uses the test outcomes to describe and develop models for information

flows and communication in ICUs between clinicians and families. The test scenarios

incorporated elements that may be pertinent to the as follows:

• Understanding: How does this website present and explain professional concepts

(ICU concepts and terms) in an understandable way to the family members of

critically ill patients in state hospitals?

• Crisis: How does this system make communication more or less effective in a

crisis situation between professionals and the public (ICU staff and families of

critical ill patients)?

• Uncertainty: How does the web help in reducing the feelings of uncertainty and

confusion of families when a loved one is admitted to an ICU?

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• Knowledge: How does the web provide general written medical information

about the ICU in the state hospitals compared with verbal or face-to-face

communication?

• Information needs: Is the end-user “family” satisfied with what they found on

the web?

For the work of this thesis open-ended questions are used for the post-test questionnaire

and closed questions for the pre-test questionnaire. (These questionnaires are in the

Appendix VII and Appendix VIII).

The Scenarios:

To prepare for the usability tests three scenarios were designed in a storytelling form,

with assistance from two doctors who work in the two main hospitals in the state who

have good experience in critical care units. These scenarios incorporated emotional

effects and add motivation to reach the goal of this usability test. Every scenario has

particular tasks to be done during the test by the participants. To ensure high efficiency

and accuracy of the data collected, the questions of the scenarios are varied to meet the

emotional and human aspects of the situation and for the sake of identifying the actual

points of view of the family members of the ICU patients on WBIS.

The first scenario represents a lady admitted to an ICU after removing a tumour from

her uterus. The second scenario is about a forty-year old man suffering from a heart

attack. The third scenario is about a young man who has been admitted to hospital many

times because he suffers from Diabetes Mellitus (DM). See Appendices (I, II and III)

Conducting the Usability Test

In order to make the testing as realistic stressful and emotional as possible, a "short

movie" was selected which involved someone with a critical medical condition in the

ICU and this movie was shown to a group of volunteers instructed to imagine they were

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the family members of the loved one in the ICU. Then, the volunteers were requested to

look for relevant information regarding this condition on the Web-Based Information

System (WBIS). Questions were then posed to this group and their answers were

recorded, revised and analysed, in order to be used for further Usability Testing.

These ten participants then worked in pair for each usability tests. The researcher asked

the Pre-Test-Questions to fill out about the participants’ backgrounds at the ATUL

laboratory. Then, each pair of participants were given the three different ‘Scenarios’ and

access to the ICU Web-Based Information System (WBIS). Each pair of usability

testing consumed almost one hour.

In the usability laboratory, the scenarios were explained to the subjects before they

proceeded to carry them out. During the tests simultaneous recording is made on

videotape of the whole room, the computer screen, the user’s facial expressions and

hand movements and audio as well as being prompted by the facilitator. The post-test

interview is also recorded.

Analyse the test records

The taped recordings of the usability test were reviewed in the context of the test goals

and system purpose. The purpose of this research is not only to evaluate whether or not

the selected health information web site meets the needs of users, but also to provide

informed recommendations with regard to the Web based Information Service to

facilitate the communication between Intensive Care Units’ clinicians and patients’

families.

The usability tests provided feedback about the degree of satisfaction of the relatives of

patients treated at the ICU regarding what they found on the website, which is

considered as a secondary yet important source of information. From views of the

surrogate families of patients treated at an ICU, the current WBIS provides general and

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accurate information about the treatment of their family member, such as detailed

information about different cases treated at the ICU. In addition, the current WBIS

provides information about the environment and structure of the ICU, in terms of the

medical tools and equipments used in the ICU. Further, relatives and close families of

patients would like a process that gives detailed and written information about their

patient’s condition. This is because families and relatives of patients in general are

under distress and unable to fully understand and comprehend the technicality of the

medical language of doctors and other medical staffs.

Table 4.4 shows some of the comments made by subjects during the usability tests.

Table 4.4: Sample of Participants Answers

Sample of participants answers from post-test questions:

It is good because if doctors are busy one can go home and find out about what is happening.

We didn't notice any room for feedback or open discussion.

We want both the doctor and nurse to tell us and then we want something to take with us

because we will forget half of what we were told.

Website doesn't allow interaction with other users or professionals.

We prefer the website was dynamic and allows life interaction with support groups and other

professionals and relevant personnel.

We prefer in crisis situation to use this website Because of possible difficulty to face medical

language.

It doesn't update the patients' condition.

Suggesting opening room for discussion and letting the community exchange their experiences.

Also to be able to write to the doctor.

Translation wasn't available for all parts of web.

Information is very general. There isn't enough information about the patients.

It was useful but not very helpful.

For the medical terminology the website was very helpful in terms of referring to the translation

to find out the definition for some words.

Website has links to other ICUs in other hospitals and we tried to look into different ICUs but

the information wasn't sufficient.

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The usability test focused on exploring the level of satisfaction for families and relatives

of ICU patients on the existing Web-Based Information System (WBIS) as a second

source of information. The special circumstances of sadness and stress involved in the

minds of relatives of critically ill patients were taken into consideration.

The positives:

* The participants representing the family members of patients considered this

web site WBIS-useful for general medical information about the patient. It offers

them the opportunity to know what is happening in the ICU, in case it impossible

to get direct information from the doctors and nurses.

WBIS saves time and effort to get the medical information required about ICU

patients. It contains a lot of information about general ICU procedures, visiting

hours and restrictions, locations of hospitals, services provided such as religious

needs, medical terms, and includes relevant medical links for those that want

further information. The visitor information page provides basic facts and

frequently asked questions related to an ICU. This aids in reducing the anxiety and

stress of the general public who requires such information.

Content for the general public is under links such as, ‘what is an ICU? Where are

all the ICUs in NSW? What is wrong with me? What sort of technology is used in

an ICU? Who is caring for me? Procedures in Intensive Care, Visiting in Intensive

Care and Frequently Asked Questions (FAQ)’.

Overall, the convergence of content for the general public is quite fine as there is an

immense amount of information available. In addition to this, the language used is

appropriate for the general public even though some medical jargon or terms are used.

Some Information is also translated for non-English speaking users.

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* The WBIS website is useful as a source of written information that can be

referred to and read several times.

* The availability of translation services for some parts of the website is useful for

"multicultural communications", especially for non-English speaking members.

* WBIS is a good means of communication because the information is presented

in a simple language compared to when talking directly to doctors who are likely

to speak in a more professional language.

The negatives:

* There is a need for a patient's family to be assured of the current medical service

provided to their patient. The website is totally lacking in this information because

the patient's family is incapable of communicating directly with the ICU where

their patient is.

*It contains a huge amount of information that confuses the searcher, who is

looking for specific information.

*It needs to have a suitable multimedia interface presentation, such as video and

audio clips, flash animation, diagrams and 3D graphics.

*It lacks the sufficient medical information sought by the patient's family

members.

*There is a need for all the sections of the website to be translated for all family

members. (One of the participants spoke English as a second language and wanted

to read the information on WBIS in his first language).

Although it was always only intended as an adjunct or secondary information source to

the preferred face-to-face, personal information exchange, it was useful to observe the

usability of the site by the relatives of ICU patients. The usability tests showed that the

website is easy to use and users can find what they wanted quite quickly. The surrogate

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family members, however, declared that they were not completely satisfied with what

they found on the web service, since it lacked any provision to have up to date and

detailed medical information about their sick family member. They emphasized the

belief that verbal communication is better than written communication in critical

situations, as they wanted to meet clinicians face to face to have more of an explanation

and to know more about the treatment in the ICU. The participants preferred and

demanded that WBIS becomes more dynamic to enable the seeker to be updated with all

accurate information about their relative's condition in the ICU.

In terms of evaluating the WBIS from the perspective of Intensive Care patients'

families (ICU), there needs to be continued assessment of the level of satisfaction with

the accuracy, sufficiency and accountability of information available on the web site

(WBIS) as new changes are made. There needs to be an evaluation of the quality of

information released in terms of the ICU environment, e.g. the equipments used,

employees working in the ICU and the visiting hours of patients. In addition, it is

important to find out whether there is satisfactory information on different ICUs in

NSW hospitals, and to inspect all relevant information that might be of importance to

the families and relatives of the patients.

In the future, the test may include having someone prepared to play the role of clinician.

Following the experiment, the participants, who all had a technical background, were

motivated to offer help to the web service management to develop the service further.

The analysis of data obtained from ICU patients' families through the "usability Tests"

clarified that the website provides mainly general information to better understand

ICUs. The website cannot be a replacement of face-to-face communication through

which the families can find assurance and are able to get more accurate information

about what is happening in regard to their family member in the ICU. Face-to-Face

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communication is the means to fulfil their need for more information, as the website

doesn't allow interaction and direct communication with ICU workers.

The website helps patients' family members gain a better understanding, and reduces

psychological stress and fears patients' families are under because their relative is in a

critical condition. This leads to better caring for their patients and also more

understanding of the nature of ICU work. It may also assist the families in sharing

important decisions made by the doctors and ICU workers about the health of their

patients.

This research is designed to assess efficiency of the website’s WBIS, as a tool or

resource for medical information, taking into consideration that Internet and electronic

sites are common sources of medical information to the public. This chapter recognized

the points of view and expectations of WBIS users in NSW. The aim is to establish

more understanding of the communication nature between health providers and patients'

families in the ICU environment, and to come out with the best means for providing

information on WBIS in a satisfactory manner, which meets the expectations and needs

of its current users. This would serve to improve the efficiency of communication

between health service providers and patients and their families.

I find here that the results of this research indicate how significant the aim of this WBIS

is to strengthen communication between all concerned stakeholders in the NSW health

system identified as expert groups, e.g. clinicians and consumers found in state.

In addition to being a public site, it is also important on national and international levels

in providing accurate information on ICU services in Australia. Hence, it all helps to

improve the medical services provided to patients and their families, and better

recognise the needs of the specialists and workers in the ICU.

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4.6 COMPARISON WITH ANOTHER AUSTRALIAN HEALTH

WEBSITE

After completing the analysis of the Usability Tests of the ICU WBIS, the researcher

was asked to conduct a usability study to evaluate a web site about to be redesigned for

palliative care in Australia for general public use. This study used the same approach as

described in Chapter 3, and the results are presented here for verification, and to add to

the information used for the subsequent phases of this research.

4.6.1 The Usability Tests

The current Caresearch website3 was the one tested. The activity–based usability testing

technique was used to get feedback from the end-user’s perspective on patients and

families. This approach involves surrogate users who are given scenarios as realistic as

possible to simulate the nature of the needs for palliative care in Australia. These

scenarios help motivate participants and ensure the success of the usability test.

Realistic scenarios were developed based on the intended audience of the web site.

The usability tests aim to provide feedback about the degree of satisfaction of patients’

need for palliative care services regarding what they found on the website, which is

considered as a second important resource of information in the field. In order to get

effective information from the usability testing, the scenarios were based on short

stories that had some emotional content so as to add motivation for users to fulfil the

aim of the usability test. For this reason, some emotional expressions were included in

the scenarios to encourage the participants to feel more compassion about the condition,

as if a real dear family member or friend were sick. Every scenario has particular tasks

to be done during the test by the participants. These scenarios are attached in the

3 http://wwww.caresearch.com.au

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appendices (IX, X and XI). As with the ICU Usability tests, Pre-test and Post-test

questionnaires were used. These questionnaires are attached in the appendices (XII and

XIII). Five tests were conducted at the Activity Theory Usability Laboratory, with two

participants for each test.

The purpose of these tests is not only to evaluate whether or not the selected health

information web site met the needs of users, but also to provide informed

recommendations with regard to the web based information service.

4.6.2 Results and recommendations based on the analysis of the Usability

Tests

*The Website (care search) has a simple design and the navigation design makes it easy

to access general information.

* The users found all the information they wanted for the three scenarios.

* The usability tests show that the website is easy to use, and users can find what they

wanted quite quickly.

* Services offered, such as search options, appear to work, and are fairly quick in

returning results.

* The reliability of this web site is fine, where most links work correctly as expected.

* The participants representing the family members of patients consider this web site

WBIS useful for general medical information about the patient.

Website saves time and effort to get the medical information required about palliative

care service in the states.”

*The participants prefer and demand that the web site become more dynamic to enable

the seeker to be updated with all accurate information about their family member in

palliative care conditions.

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*In terms of the target audiences, there is an attempt to include multicultural

communication, however, only minimally. Also, for a person who does not speak

English it would be hard for them to determine how to access this, as it is not clearly

visible on the front screen unless one scrolls down –and unless the user speaks English.

“Translation wasn't available for all parts of web”

*Some pages become overloaded with information, which can force the user to lose

focus. Some pages are too long.

“It contains huge amount of information that confuse the searcher of specific

information.”

* Lack of attractive pictures and icons is the main problem of this web-based system. It

makes the user unwilling to spend their valuable time to find information.

* They also suggest that it might be used more if the website has visual information;

especially for who are illiterate. Even video clips would be helpful.

*Website doesn't allow for interactions with other users or professionals.

“We prefer the website was dynamic and allows life interaction with support groups

and Translation wasn't available for all parts of web”

*This website lacks a discussion service and interactive communication platform with

support groups.

“Suggesting opening room for discussion and letting the community exchange their

experiences”

From the low usability evaluation there is enough feedback from the users to assist the

development team of this web site to work on future enhancements to assess the

satisfaction of the end-users.

*It needs to have multimedia and a suitable interface presentation, such as video and

audio clips, flash animation, diagrams and 3D graphics.

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* Add (FAQs) a Frequently Asked Questions section.

*Put in some kind of communication tool. Better to use a discussion board to assist this

communication. This encourages the user to contact health professionals if they are

concerned about a health issue, or wants to participate in on-line chat forums.

* Add a facility to let users get on-line help from the site.

* Try to design a more attractive homepage.

*There is a need for good structure with an organised index because the users

complained that the website is overloaded with information.

4.7 CHAPTER SUMMARY

This chapter presents the analysis of data collected from the three stakeholders, the

state-based staff and web-site developers, ICU staff and patient’s relatives. The different

research methods used with each group are most suitable for their particular

circumstances. Following information gained through several meetings and discussions

between ICCMU and the whole research team semi-structured interview with an

ICCMU manager enabled this researcher to gain an insight into the purpose of ICUs,

how they are set up and run in the larger state hospitals and how important yet difficult

communication can be between clinicians and patient’s families. It also helped me

understand their rationale in building a WBIS the way they did.

Getting data from a busy ICU was done in combination with a larger Q-study. The

statements from the concourses conducted in 8 ICUs gave the researcher the ICU staff’s

perspective in their own words, which otherwise would have been impossible. It is

thought that this data is therefore extremely valid and authentic. Conducting usability

tests using the Activity Theory method also enabled the collection of valid and realistic

data from the public’s perspective.

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This chapter also provides some background on the Intensive Care Environments in the

state of New South Wales (NSW), Australia, and details about WBIS information

resources supplied to the ICUs across the State. This WBIS service takes the form of an

online service to facilitate communication between and among the state’s regional ICUs

so that information is shared with clinicians, patients, their families and the community.

The results of analysing the data obtained from the web manager, clinicians and families

is now going to be used in developing a model clarifying the nature of communication

and information exchange between concerned stakeholders in the ICU. The following

chapter describes the development of a System Dynamics model of information flows in

an ICU. This should further improve the understanding of ICU relationships.

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CHAPTER 5: DEVELOPMENT AND PRESENTATION OF

THE MODEL

5.1 INTRODUCTION

This chapter describes Phase 2 of the research: the development of a System Dynamics

(SD) conceptual model to represent the communication between the ICU staff and

patients’ families in the stressful context of the patients’ treatment in the ICU. As

described in Chapter 3, this phase of the research creates a conceptual model depicting

and visualizing the findings of Phase 1 in accord with the Data Display element of the

qualitative research process, as shown in Figure 3.1. This holistic conceptual model

provides a means of displaying the findings of the research based on the qualitative

data, as recommended by Miles and Huberman (1994). Throughout the study, the

System Dynamics model has evolved and been a vehicle for interpreting the data by the

researchers in combination with representatives of the stakeholder groups as it has

developed over many months to its current form. The model encapsulates the

knowledge gained from the study showing the elements that are important and, how

they are interrelated. The model also visualizes the research findings in a way that will

enable the project to move forward.

As described in Chapter 2, the SD stock-flow model provides a framework in which to

get a better understanding of the nature. This approach follows the lead of others

(Demello et al. 1990, Sterman 2000, Hitchins 2003 and Richmond 2004), where SD

modelling using Stella software has been used in health care settings.

This chapter begins with an introduction of STELLA software and, how SD is able to

create conceptual frameworks and models of complex situations. It then describes how

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the researcher used the data gathered from the three groups of stakeholders to create and

improve the model through a series of iterations. A System Dynamics model was

constructed the communication between professionals (ICU staff) and public (families

of critically ill patients) identifying the relevant elements for use in the model, as well as

identifying and expressing the relationships between the variables (Barlas 1996 and

Ford 1999). Using System Dynamics for modelling such complex systems is present in

an ICU helps us to display the behaviours aspects of the elements that influence the

communication process, which are inherent to the crisis environment.

The model that emerged from this study is based on the data collected and analysed in

Chapter 4, and the literature review of Chapter 2. It is then used to re-interpret the

findings with Activity Theory in Chapter 6.

5.2 A SYSTEM DYNAMICS STUDY OF COMMUNICATION IN

ICUS

Chapters 3 and 4 justify the choice of an ICU as a suitable site for this study of

information flows between professionals and the public. In the dynamic and high stress

environment of intensive care, medical information exchanges often take place under

conditions of stress, and therefore are complex and dynamic. An intensive care unit is a

designated ward of a hospital that is specially staffed and equipped to provide

observation, care and treatment to patients with actual or potentially life-threatening

illnesses, injuries or complications, from which recovery is possible. As the patient is

usually unable to communicate, ICU staff members interact with various family

members in the course of the patient’s stay in the ICU.

The ICU is a high demand service with highly specialised equipments and clinical

resources unfamiliar to the general public. It is important that efficient information

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access be established for both clinical use and the public sharing of information in order

to facilitate usage of the limited human resources and to increase family contributions to

patient wellbeing.

Communication with families in intensive care settings is complicated because the

admission to ICUs is often unexpected, as the families are likely to be emotionally

strained. Clinicians do not always have the skills, training, time or will to deal with

family concerns, making direct interaction between ICU clinicians and family members

limited. This study shows a clear interest in the provision of a web-based support

service for critically ill patients for providing general health information and

explanations of medical terms. However, families still expect and prefer to

communicate directly with clinicians to obtain information specifically related to their

family members’ medical conditions.

This research continues to investigate whether providing updated information to the

families through different communication channels might be helpful in decreasing

families’ stress and increasing their certainty of their family member’s progress. Most

communication and information exchanges occurring within ICUs are informal and will

not be captured in formal computer Systems, and the WBIS developers have little

interest in supporting this type of communication.

As explained in the literature review presented in Chapter 2, there are a number of ways

written documents and ICT can be used to communicate information to patient and their

families. The two communication channels, informal/verbal and written/online, provide

different degrees of effectiveness of communication between doctors and families of

critically ill patients. This study looks at the information from the viewpoints of both of

them, through the data collection and analysis of views of different stakeholders. This

study aims to explore the nature of communication and determine ways to improve

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health information services; both as a general issue of professional-public information

flow and, a particular instance of the state’s current WBIS, designed to enhance

communication and information provision so ICU staff and the public can share

valuable knowledge gained in the experience of practice.

To this end, in Phase 2 of the research, a System Dynamics, stock-flow model was

created to help make sense of the data collected; this was analysed in Phase 1 as

presented in Chapter 4.

This chapter discusses the development of the model, as a conceptual representation of

the system to help create better communication between clinicians and families of the

patients in Intensive Care Units.

5.3 THE CONCEPTUAL MODEL DESIGN

This conceptual SD stock-flow model evolved over a long period of time, from the start

of the review of the literature to the completion of the data analysis of Phase 1. The

model was refined using feedback from stakeholders and through many meetings with

my supervisors. This repeated re-evaluation of the model provided more ideas that

would help to re-build the model to give a realistic representation of the dynamic nature

of communication in the ICU and the relationship between elements of that system.

This section of the chapter begins with an illustration of the modelling process, and then

with the identification of the elements of this model, which are grounded in the analysis

of data collected in Chapter 4 and, in the literature review of Chapter 2. The SD model

was built using STELLA software version 9.0, which has a language that follows rules

of grammar appropriate to a Stock-Flow model. As described in Chapter 3, the basic

language elements of STELLA are stocks, flows and converters.

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5.3.1 The Stocks and Flows

Stocks: are nouns and, represent accumulations of things. In System Dynamics they are

represented by a rectangle. It is clear there are at least three important stocks in the

communication model to illustrate the information exchange in the ICU, between ICU

staff, families and relatives of the patients. In the ICU communication model, as will be

explained below, the following Stocks are chosen:

< FAMILY UNDERSTANDING

< RELEVANT MEDICAL KNOWLEDGE (of the ICU Staff)

< PATIENT CRISIS LEVEL

From the analysis of data gathered from the two groups of stakeholders that participated

in the communication, key corresponding STOCKS were identified with appropriate in

and out flows, as shown in Figures (5.1, 5.2 & 5.3). For the family members, this was

the UNDERSTANDING of what was happening to their loved one, while for the

clinicians it was their RELEVANT MEDICAL KNOWLEDGE generated by, and

applicable to, the case at hand. Both these stocks mediated and, were mediated by, the

patient’s condition, which is represented by the stock PATIENT CRISIS LEVEL.

FAMILY UNDERSTANDING

Using the data analysis, understanding the families is the most important issues across

all three stakeholders. Web-site developers’ priority is to provide detailed and sufficient

information for patients and families to increase their understanding and reduce their

stress and confusion. From the families’ points of view, in terms of the results of the

usability test, patients and their families mainly seek information regarding medical

procedures, services and facilities in the ICU. On the other hand, according to ICU staff,

web based information helps patients’ families to gain better understanding of the

medical issues in general.

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In the literature, communication between clinicians and family members is an important

factor influencing outcomes for families of ICU patients (Molter 1979; Azoulay et al.

2003; Engström & Soderbergh 2005; Hughes et al. 2004); as is the seeking of health

information from different sources of information, mainly verbal and written medical

information (Fries 1998; Johnson 1999; Larson 1996).

RELEVANT MEDICAL KNOWLEDGE

From the perspective of those at the State ICU unit responsible for the website, it is

important for relevant ICU knowledge to be presented in an easy to read form and, be

available to support communication in an ICU. The ICU staff expressed difficulties in

finding time and the right approach to communicate with patients’ families. Web-based

information systems provide general medical information about ICUs, whereas patient’s

families always seek particular information about their family member’s medical

condition. Besides gathering information from the websites, it is also important for

patients’ families to communicate directly with ICU staff. The results of the usability

tests place strong emphasis on families’ needs to get relevant medical information from

both the ICU staff and the web-based information system.

The general medical information that WBIS delivers to them makes the communication

more effective (Ellis 2000; Bylund et al. 2007; Blanton & Balch 1995; Brennan1996).

Moreover, in the context of ICU settings, the crisis situation is based on the medical

conditions of the patients (Azoulay et al. 2001).

PATIENT CRISIS LEVEL

The patient’s health is the core factor that influences communication between ICU staff

and families. The rate at which the patients’ health condition deteriorates or improves

also influences the way patients’ families relate to the information and the efficiency of

communication (Bouman 2000). The interview of the website developer revealed that

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the web-based information system is more effective in a crisis situation, especially when

delivering bad news about patients’ conditions to the families, as they will likely be

overcome by grief. As such, the written information is likely to be more effective as it

can be taken home by the families in order to better help them understand the patient’s

medical situation, especially if they have to make important decisions on behalf of the

patient (Demiris 2005; Bagian 2001; Norum et al. 2003; Mirr 1991; Johnson 1990).

Flows are verbs, which represent actions that fill or drain Stocks. They are represented

by directed pipes. In the ICU communication model, the Flows for the three Stocks are:

<UNDERSTANDING: Inflow informing, outflow confusing

<RELEVANT MEDICAL KNOWLEDGE: Inflow updating, outflow releasing

<PATIENT CRISIS LEVEL: Inflow worsening, outflow improving

UNDERSTANDING

informing confusing Figure 5.1: The stock UNDERSTANDING refers to family members. It is

increased by the inflow informing and decreased by the outflow

confusing.

Figure 5.2: The stock RELEVANT MEDICAL KNOWLEDGE refers to ICU

Staff. It is increased by the inflow updating and decreased by the outflow releasing.


updatingreleasing

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PATIENT CRISIS LEVELimproving worsening

Figure 5.3: The stock PATIENT CRISIS LEVEL refers to the patient’s condition.

It is increased by the inflow worsening and decreased by the outflow

improving.

5.3.2 Adding converters and linking Stocks and Flows

When a model is built to study the dynamics of the system, a choice is made to include

certain factors that are relevant to the problem being studied. The issues that appear to

influence the Stocks and Flows, based on the literature and data analysis, are now

presented.

The amount of UNDERSTANDING, acquired from the information, provided to the

families is affected by their level of medical knowledge. As Azoulay et al. (2000)

report, half of the family members in their study did not understand what the physician

explained to them; the quality of the communication was low and their level of stress

was high. Inadequate communication with ICU clinicians contributes to the frustration

and uncertainty of family members and, this is amplified by their level of stress due to

their family member’s condition (Bouman 2000). As shown in Figure 5.4, these are

represented in the model by the converters family knowledge and stress level,

respectively.

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Figure 5.4: The confusing flow will be based on the average of the stress level and,

the informing flow based on the average of knowledge.

Figure 5.5: The updating is based on the average ICU knowledge and, the releasing

of information is based on the average of questions asked by family members

The stock of working RELEVANT MEDICAL KNOWLEDGE is required by the

ICU staff at any and all times, both to treat patients and to inform the family. Its

updating is triggered by changes to the patient’s condition (improving and worsening)

and, its release by questioning from the family. As shown in Figure 5.5, it is also

influenced by the medical capability of the ICU clinicians and the quality of both their

general medical knowledge and their knowledge of things specific to the ICU for this

patient (converter ICU Knowledge) (Sheldon et al 2006; Lloyd & Bor 2004; Stewart

1995).

UNDERSTANDING

informing confusing

knowledge stress level


updatingreleasing

questioning

ICU knowledge

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Figure 5.6: The medical condition of the patient (improving or worsening) affects

the amount of information that ICU staff get and, the varying level of need for

communicating with patients’ families.

communication

stastic web

dy namic web

legal

tecnical

v erbal

communication skills

Figure 5.7: This all leads to communication between family members and ICU

staff through face-to-face communication, or WBIS.

The converter communication (Coiera 1997), on the left-hand side of the model, shown

in Figure 5.7, is critical. The results of the research have been used extensively to

incorporate various parameters into this section of the model, as follows:


Releasing Updating

Questioning

ICU knowledge

PATIENT CRISIS LEVEL

Improving Worsening

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• The quality of traditional verbal communication affected by converter

communication skill (Stewart 19995; Lloyd & Bor 2004; Ruiz-Moral et al. 2006).

• There is a role for a static web-based information service, as is currently the case in

this study. This service is unable to provide updated information about certain cases,

so families are not able to communicate with hospitals through this service to access

their patients’ medical conditions. This view is based on the results of the usability

tests and the interview with the WBIS management. Types of communication

include verbal and non-verbal communication such as body language, kinesics

(visual and tactile) and proxemics (distance between communication partners)

(Pauwels 1995; Oliver 1991; Scott et al. 2001).

• The possible role of a dynamic web-based information service (Coiera 2003; Bylund

et al. 2007; Gustafson 1999 & Bagian 2001) is projected as many stakeholders

report that this is important to meet users’ needs for specific information about their

patients.

5.3.3 The Evolution of the Conceptual Model

Initially, a first model was produced based only on a description of the situation given

by the web site owners and designers in the State ICU Coordination Unit. This produced

the simple conceptual model shown in Figure 5.8, which contains two stocks, the

UNDERSTANDING of the family of a critically ill patient and, the MEDICAL

INFORMATION of the ICU clinicians. Information flows from the latter exist to

improve the former, aided by suitable content on the web page. The understanding of

the family members would be enhanced by their level of medical knowledge, but

diminished by their level of stress due to their concern for the patient.

This model represents:

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• Family members’ need for information about the patient’s condition and general

medical information about the ICU (Molter 1979; Azoulay et al. 2003).

• ICU staff members (administrators/nurses/physicians) that are authorized to

provide the relatives of patients with the necessary information and answer their

questions (Clarke & Aiken, 2003; Soderstotm et al. 2003; Azoulay et al. 2000).

• The web information service provides general written medical information about

ICU procedures and equipment in the state hospitals to supplement day-to-day

information from direct contact with the ICU staff. The WBIS benefits them by

offering a freedom from location and more efficient use of time for the users

(Ellis 2000; Demiris 2005; Bagian 2001).

Figure 5.8: The first conceptual stock/flow diagram that shows a simple flow of

medical information to patients’ families to enhance their stock of

understanding, based on initial discussion with the web-site owners and

designers in the State ICU Coordination Unit.

The model in Figure 5.8 was enhanced by items in the literature review and the analysis

of the data collected, as described above from the three sets of stakeholders: members of

UNDERSTANDING

informing confusing


information quality

Web

verbal

MEDICAL INFORMATION

updatingreleasing

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the State-based ICU Coordination Unit, responsible for the web-site; the ICU clinicians

and, the surrogate family members. This produced the model shown in Figure 5.9,

which integrates all the available data into a consistent framework for the new model,

which has a more complex stock and flow structure. Although much iteration occurred,

the most prominent items added to the model are:

• A stock named, CRISIS LEVEL, representing the condition of the patient.

Changes to this prompt the need for communication, and the level itself provides

a means of determining the family’s stress level.

• The desire of the family to have a dynamic website (not yet implemented) with

up-to-date information about the patient, whom they are concerned about (not

just static general information).

• Some feedback representing questioning by the family members.

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Figure 5.9: An enhancement of the model of Figure 5.8, using the literature and

data analysis.

At regular intervals the model itself was used to elicit feedback from various

stakeholders involved at the data collection stage and, from others familiar with Stella

modelling. This resulted in further changes to the model have shown in Figure 5.10 and,

introduced several more influencing factors, as follows:

• The quality of MEDICAL BULLETINS for the family is determined by both the

general medical capability of the ICU clinicians and their knowledge of things

specific to the ICU.

• The communication skills of the ICU clinicians.

• Conflicting technical and legal issues that would affect the feasibility of the

dynamic web site.

UNDERSTANDING

informing confusing


information quality

dynamic

static

verbal

questioning

MEDICAL DATA updatingreleasing

CRISIS LEVEL

improving worsening

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These changes are represented in the current version of the model shown, as is shown in

Figure 5.10.

UNDERSTANDING

informing confusing

family knowledge stress level

communication

dynamic web

static web

verbal

questioning


updatingreleasing

PATIENT CRISIS LEVELimproving

worsening

communication skills

ICU knowledge

legal

technical

Figure 5.10: The current state of the conceptual model integrating the three stocks

with converters and connectors based on the literature and analysis of data from

the research

5.4 MODEL VALIDATION

Testing the conceptual model involved repeated judgment of both experienced

modellers and individuals with knowledge of the actual system, in some of the state

hospitals. After many detailed discussions between the modelling team and these

evaluators, there were suggested changes until a reasonable stable version of the model

was produced.

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The main justification for the modelling approach in this phase of the research is the

way it enables a new perspective on various aspects of the problem at hand.

According to Preece et al. (2002), good interaction design aims to enhance the way

people communicate and interact by creating user experiences in the way that support

their activities. However, in this study, the web site owners at the state level indicated

that the dynamic site would be limited by factors represented by converters legal and

technical. They raised issues about security, authorized access, etc. (Bias & Mayhew

1994). Technical, ethical and professional questions would surround the introduction of

WBIS to the ICU. The ethical issues include privacy and confidentiality. The operation

issues include security, redundancy, reliability and quality. These challenges aligned

with the goal of the interaction design to ensure the interactive systems are effective,

efficient and safe to use.

It should be noted that there is a need for using information technology and

communication tools to enhance and improve communication, understanding and

management of health information to foster the relationships among the health system

and its environments and, to enhance and improve all aspects of the patients care.

According to the interview with the manager of this current WBIS, in respect to the

communication between the healthcare team (ICU) and families, the web site provides

general health information; this service would not replace personal communication, but

was designed to help provide more support for family members who are in shock and

under stress as they can’t absorb information as well as normal. When they need more

explanation, sometimes the best way to give information is in written form rather than

verbally. This can also save the valuable time of nurses, who often have to explain the

same issue multiple times to different family members, or even to one person who is

stressed and confused.

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It is readily apparent that substantial effort has gone into developing the content of the

web site and ensuring the quality and suitability of its presentation. It contains a

measured amount of authoritative basic ICU knowledge in a language that is

understandable by the non-professional. The web page uses a consistence minimalist

design that is appropriate to its use. Considerable effort has gone into the translation of

much of the information into the several community languages of the major immigrant

communities in the state. Anticipated modes of use are on a computer in the waiting

room, printed off in conjunction with verbal communication, or having the family

advised to lookup information on the site at home.

The collected data from ICU staff, the second stakeholders, indicate that the website

seems to be an important source of information for families in specific areas. They

agreed that it would save their time if they could download information from this web

page and give it to patient’s relatives. They agreed that this WBIS would help the non-

English speaking patients and their families by providing a translation service for some

pages on this web site to get a better understanding of the ICU setting. Clinicians and

patient web-based systems are now being integrated with clinical Information Systems

and management Information Systems to offer patient-focused information,

communication tools, and administrative functions (Bagian, Lee & Gosbee 2001; Coiera

2003 & Anderson 1997).

From the view of family members of critical ill patients, they said that although it was

always intended that the website serve only as an adjunct or secondary information

source for the preferred face-to-face, personal information exchange, it was useful to

observe the usability of the site by the general public. The usability tests showed that the

website was easy to use and users could find what they wanted quite quickly. The

surrogate family members, however, declared that they are not completely satisfied with

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what they found on the web service, since it lacked any provision to have up-to-date and

detailed medical information about ‘their’ patient. They emphasised the belief that the

verbal communication is better than written communication in critical situations, as they

wanted to meet clinicians face to face to have more explanation and to know more about

the treatment in the ICU. This shows a limitation of laboratory based testing, which

could be improved with more planning. Following the experiment, the participants, all

with a technical background, were motivated to offer help to the web service

management to develop the service. In the future the test may include having someone

prepared to play the role of clinician.

The two most important aspects of the problem, as depicted in the model that are of

current interest to practice are, firstly, how to use technology in a more interactive way

to improve information flows between ICU staff and families of patients, and secondly,

to see how improved communication leads to better health outcomes. The first of these

appears on the model as legal and technical constraints on the development of a

dynamic website. These issues are currently a point of discussion with out first set of

stakeholders, the state-based staff and web-site developers. To resolve the second issue,

it may be useful to consider how to include in the model feedback from the

UNDERSTANDING of families to the patient’s wellbeing. More data is needed to

determine just how this can be done.

5.5 CHAPTER SUMMARY

This chapter presents and describes the development of a SD model within the ICU

environment, where communication between ICU staff and family members of critically

ill patients takes place.

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It begins by the conceptual model of the communication in an ICU environment is

emerged, based on the data collected and analysed in Chapter 4 and, the literature

review of Chapter 2.

This chapter explains the evolutionary process of building a conceptual System

Dynamics model using STELLA software to represent and visualize information flows,

subsequently increasing understanding within critical environments such as those found

in an ICU.

Based on the results of the modelling process, the next chapter presents the final

analysis that uses Activity Theory to further explore the relationships of communication

tools and processes of use in real dynamic crisis activities. Activity Theory is concerned

with explaining and analysing human behaviour in complex systems. Activity Theory

adds more depth to the research, as it is an approach that conceptualises the

relationships between individuals, communities, technologies and activities, which

consider the tool to be mediating human interaction with the world (Kuutti 1999).

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CHAPTER 6: THE ACTIVITY THEORY ANALYSIS

6.1 INTRODUCTION

This chapter presents a deeper analysis of the communication within ICU that was

depicted in Chapter 5, in a System Dynamics model. The analysis presented here uses

Activity Theory as a framework, particularly because it includes elements of the

community, the social context, the tools and most importantly, the relationship between

various less tangible concepts in the environment. The theory has a basic structure for

application to a problem, but is flexible in the way it can be applied to different research

projects in different fields. Activity Theory brings the focus not only onto the main

communication activity but also onto the activities for which information is used. In our

case this concerns the work of the clinicians, together with the family, towards the

treatment and well-being of the patient.

As described previously in Chapter 3, Activity Theory provides a particular definition

of human activity that can be adopted as a unit of analysis for qualitative research into

complex situations, as in critical care situations in ICU. This approach to research works

on recognizing and defining an activity, supported by its actions and operations. As

presented in Chapter 2 (Figure 2.2) I have used Engeström’s triangular frame work of

an activity as this has been popular in IS research. It consists of motivation, goals, tools,

an object, an outcome, rules, community and division of labour; these are the key

elements of the holistic unit of analysis. However the essence of an activity from the

work of Vygotsky (1978) is the dialectic relationship between subject and object, i.e. a

person working at something where tools and community play a mediating role. Other

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elements of Engeström’s triangle are secondary to the core elements of subject, object,

tools and community and can be omitted from any analysis of an Activity System.

There are many research approaches for studying and modelling human behaviour in

complex systems. However, they often ignore the impact of human, social, cultural and

context factors. Activity Theory places the focus of analysis on the activities that are

carried out by people in support of their interpretations of their role, the opportunities

and resources available to them, and their purpose, for which the activity exists. This is

both subjective, in the sense that it is a matter for individual interpretation, and

objective, in the sense that the motives, purpose and context are vital part of human

work. From this perspective, an activity is a completely meaningful unit of analysis

when studying the way people work.

Activity Theory has been used in IS research as a developed framework for analysing

the complex dynamics of the settings, which usually involve interacting human and

technical elements such as computer based systems, as humans use information and

communication technology to carry out their activities effectively in the modern work

environment. Activity Theory is therefore appropriate for many modern environments

where sophisticated ICT tools mediate work in a complex work and social context, as in

the real life health care environment, which is evaluated in this study.

6.2 THE PROCESS OF USING ACTIVITY THEORY

The Activity Theory framework is used here to get a better understanding of the

different ways of communication by which professionals interact with the public in

crisis situations within the health care system.

Up to this point in the research, data has been gathered from three groups of

stakeholders. The results of this initial analysis are presented in Chapter 4. This data,

together with the literature review of Chapter 2, fed into the creation of a System

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Dynamics model, which emerged from the analysis in Chapter 5. The outcome of this

modelling process is now subjected to further interpretation with Activity Theory as the

chosen framework to analyse, with greater depth, the techno-social situation of the

health care setting.

6.2.1 Description of the Analysis Process

This study investigates the communication in crisis and critical situations in health care

settings, in this case, the ICU. As described in previous chapters, communication with

families in ICU settings is complicated, and the families are under difficult emotional

circumstances. They seek information from the healthcare professionals and other

sources such as the Internet to make important decisions about their patient health

situation. In Chapter 5, this was modelled using SD, and the result are the starting point

for the Activity Theory analysis presented in this Chapter.

In Section 3.5 of Chapter 3 the three steps for any Activity Theory analysis were

described, and the analysis here begins with these. Step one is concerned with the

importance of establishing what is the central activity, or main two or three activities of

interest. Step two concerns the identification of the mediating role of the tools that are

used by particular subjects, i.e. those performing the activity (Hasan2003a). Step three

concerns the whole activity system where activities that interact with the central

activity.

6.2.2 Identifying the Core Activities of the System being Investigated

An Activity Theory analysis begins with a description of the central activity or main

activities and the relations between them.

As described in Chapter 3, an activity is the engagement of a subject toward a certain

goal or objective. An activity is defined by the dialectic relationship between a subject

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(i.e. a person or small group of people), and the object of their work, which includes

purpose, motive and context. A work team would be a collective subject composed of a

group of individuals who bring different skills and understandings to bear on a common

object.

In this step of the Activity Theory analysis, the core activity of the system being

investigated is identified and then used as the central activity of the whole activity

system. This system includes the elements and tools mediating that activity as well as

other activities in the system. Thus, the choice of core activity determines how the

whole system is viewed. In this case, the core activity of an ICU is the care of the

patient, while the focus of the research is the activity of communication between the

ICU staff and family members. Both of these are options for core activity is considered

later in this chapter.

6.2.3 Identifying the Mediating Elements and Tools

As depicted in Chapter 2 in the triangle of Figure 2.3, an activity both mediates, and is

mediated by, the tools used and the social context of the work activity. This two-way

concept of mediation implies that the capability and availability of tools mediates what

can be done and the tool, in turn, evolves to hold the historical knowledge of how a

society works and is organised. Tools expand our potential to manipulate and transform

objects, but also restrict what can be done within the limitation of the tool, which, in

turn, often stimulates improvements to the tool.

Tools that mediate human activity can be primary (physical), secondary (ideas, models,

etc) and tertiary (communities, context, environment, etc).

This research is particularly interested in the primary, secondary and tertiary tools that

mediate activities concerning the flow of information in an ICU.

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Primary tools for activities concerning information flows include face-to-face meetings

and online communication using computer-based information systems. The latter are of

particular importance for the outcomes of this research and can be used by both ICU

staff and families as a primary tool to seek health information, as well as to

communicate and exchange information.

Secondary tools include medical knowledge, communication skills, previous

experiences and language, which may be different for each group of subjects. ICU staff

members use their own medical and professional language, while the second group

(family) use the language of the general public. Many of these may have multicultural

identities and backgrounds, which can make communication even more difficult,

especially when it is face-to-face.

Tertiary Tools include the context (such as stress levels due to the patient’s medical

conditions). Understanding the medical information families are receiving from the

medical staff helps to reduce their stress, improving decisions made on behalf of the

patient.

6.2.4 Identifying the Activities that Support the Core Activity

As described by various researchers mentioned in Chapter 3, an activity system usually

has a central activity, which is surrounded by other related activities (Hasan 2003b;

Engeström 1999 & Virkunnen 1995).

The main concern in this study is that the subjects use a computer-based system for

seeking medical information to get a better understanding about health professional

terms and vocabulary.

In such a social-technical environment, there is an interaction between the activities.

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The purpose of those activities for the subjects is to improve communication and avoid

some of the communication challenges that intensive care workers and families face

when caring for a critically ill patient.

6.3 INITIAL ANALYSIS - WITH THE PATIENT CARE ACTIVITY

AS CORE ACTIVITY

This researcher began this Activity Theory analysis by interpreting the stocks of the

System Dynamics model as activities. There are three of these, as shown in Chapter 5

Figures (5.1, 5.2 & 5.3), involving the patient, ICU staff and families of patients,

respectively.

From an Activity Theory perspective that views the ICU as a whole, it would be normal

to regard caring for the health of the patient as a core activity, since treating patients is

the basic purpose of an ICU. This activity would correspond to the stock, which

measures the crisis level of the patient.

6.3.1 The Core Activity

Figure 6.1a: The Core Activity

6.3.2 The Mediating Elements and Tools

As stated in Chapter 3, Activity Theory emphasizes that “tools” mediate Human

Activity in a broad sense, as tools are created and transformed during the development

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of the activity itself, and carry with them a particular cultural and historical meaning

from their development.

There are different kinds of tools relevant to this first Activity Theory analysis, namely:

Primary Tools – ICU equipment and the medical skills of staff.

Secondary Tools – Communication between ICU staff and family should contribute to

the better care of the patient resulting in improved patient outcomes.

Tertiary Tools - ICU culture.

6.3.3 Supporting Activities

Activities supporting the core activity of patient care would include activities based on

the two other stocks from the Systems Dynamics model. It is the other two stocks that

are more relevant to the focus of the research, which is the communication between the

clinicians and members of the public. These two stocks include ICU staff’s relevant

medical knowledge, and families’ understandings of the patient. Both groups are users

of computer-based systems of health information. The corresponding activities are

shown in Figures 6.1b and 6.1c.

Figure 6.1b: Supporting Activity 1

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Figure 6.1c: Supporting Activity 2

Most relevant to this research is the concept that the interaction of these two activities,

which is the communication of relevant medical knowledge to the families of patients,

is a secondary tool to support the core activity of patient care. This is depicted in Figure

6.5.

Figure 6.2: The Holistic Model of the three Activities in this Research

This Activity Theory analysis of the situation in ICU depicts an important feature of the

problem under investigation, namely that communication between ICU staff and a

patient’s family is an important tool in the care of the patient. It does not, however, offer

much help in focussing on the communication itself, as an activity supported by ICT

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tools. A re-interpretation, focussing on the activity of communication was then

undertaken, as described in the following section.

6.4 SUBSEQUENT ANALYSIS WITH COMMUNICATION

BETWEEN ICU STAFF AND FAMILIES AS THE CORE

ACTIVITY OF INTEREST

In this section, an alternative Activity Theory analysis of information flows in an ICU is

described, based on the literature and data analysis described in Chapter 4. Here,

communication is chosen as the core activity in order to include various tools that

mediate the communication.

6.4.1 The Core Activity

The core activity, communication, is depicted in Figure 6.3.

Figure 6.3: Communication as a Core Activity in this Research

For the purpose of this particular research analysis, communication is used as the core

activity. It is assumed that, in addition to improving the understanding of the family,

communication has a significant impact on patients’ health outcomes. A patient’s family

has information needs that include accurate, timely and detailed information about the

patient’s medical situation. It is up to them to make important decisions for the critically

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ill patients, who may not be able to make any decisions about their health themselves

due to their diminished capacity.

From the System Dynamics model, the ICU nurses have to provide the information

based on the patient’s crisis level or health condition. The ICU staff’s ability to

communicate, and their medical knowledge, provides the basis for them to

communicate effectively with the patient’s family. The patient’s family rely on ICU

staff to understand the patient’s condition, but their level of medical knowledge and the

level of stress they feel from concern for the patient affect this understanding. What is

not included in the system dynamics model is the effect of this understanding on the

wellbeing of the family, who may need to make decisions on the patient’s behalf.

6.4.2 The Mediating Elements and Tools

There are two kinds of primary tools for information provision relevant to this study;

namely, traditional face-to-face communication and a WBIS. In the traditional method,

communications can either be formal or informal. Formal communication is where the

ICU staff’s approach to the family informs them of the patient’s situation. On the other

hand, in informal communication, the patient’s family can approach the ICU staff to

seek information about the patients either when visiting the patients in the ICU unit, or

accompanying the patient to the ICU unit. The major challenge in traditional

communication is that ICU staff members do not have enough time to communicate

with the family, as they are in between attending patients while undertaking their

professional roles.

Another important concern is ethnic barriers. Because patients and their families are

from various diverse ethnic backgrounds and may speak different languages than the

ICU staff members, they may not be able to communicate with them effectively without

interpreters.

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The WBIS provides a supportive information source and an efficient electronic system

for an ICU to exchange information via the Internet. Thus, the WBIS can be used to

improve the quality of a patient’s care. It includes written information for various

medical conditions as well as the public being able to print out details of procedures,

visitor hours, locations and parking. The WBIS should decrease the distress of relatives

and improve the quality of service for the patients. In addition, the WBIS should

provide translations for non-English speakers so that doctors are able to communicate

with them more easily. However, for the WBIS to be effective, the users have to be

computer literate or have Internet facilities.

A secondary tool for the activity of communication is the relevant medical knowledge

of those involved, as discussed previously. The main tertiary tool is the culture and

environment of the ICU, which is strongly influenced by its critical nature. As

mentioned in the Introduction to this thesis, this is seen as the particular case of many

critical situations such as natural disasters, criminal events and so on. The core activity,

with mediating tools and community, is depicted in Figure 6.4.

Figure 6.4: The core activity of communication with most significant mediating

tools.

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6.4.3 Supporting Activities

As discussed above, the core activity in an activity system is related to other activities

surrounding it. Figure 6.5 illustrates the relationship between activities where

communication is the core activity. The activities of the three stakeholder groups of this

research are the related or supportive activities to the main or core activity

(Communication). Firstly, the activity of ICU staff members, identifying and preparing

relative medical knowledge, with the availability of time and the ability to explain the

medical information to patients effectively. Secondly, the family’s ability to understand

medical information is affected by their stress level, language barriers and their previous

knowledge of either ICU procedures, or other factors related to the patient’s medical

condition. Thirdly, those in the State-based ICU Monitoring Unit are developing the

WBIS as a tool to support the communication. They are engaged in the tool creation

activity for the communication between the ICU staff and the families of patients. These

are the key activities that affect the activity of communication in the ICU.

The relationship between all five activities, namely communication, patient health,

family understanding, ICU staff application of medical knowledge, and the web

development, is shown in Figure 6.5. This represents the activity system where good

communication leads to improved patient outcomes. It should be noted that the critical

activities of treating the patient are outside the scope of this research and so are not

included here.

The concepts and language of Activity Theory give substance to the models in Figures

6.4 and 6.5. With communication as the core activity giving better patient health as an

outcome, it is helpful to consider face-to-face and WBIS information flows as the

primary tools that mediate the communication. It should be remembered that mediation

in Activity Theory terms is a dynamic two-way relationship. The implications of this for

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the ongoing development of the WBIS are discussed below. The secondary and tertiary

tools such, as stress and culture of the ICU environment, are also considered in this

discussion.

Figure 6.5: The Activity System that makes Communication the Core Activity (a

more suitable choice for this research)

6.4.4 Implications of this Activity System

The Figure 6.5 draws on the holistic framework of Activity Theory to analyse the

system of communication in ICUs, depicting the elements of face-to-face and web-

based information flows in accord with the focus of this study: an exploration of the

communication issues between clinicians and the families of ICU patients. In the

previous chapter, SD modelling was used to investigate the nature of communication.

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This chapter presents the Activity Theory model, which displays the research findings

to better understand the communication between professionals, here intensive care unit

staff and family members of critically ill patients, particularly in crisis situations. The

significance of communication in this system serves the greater purpose for the family,

which is to help understand the patient’s medical condition and required treatment.

The Intensive Care Unit (ICU) is a highly technical environment and involves constant

interactions between the ICU staff and patients’ families. Hence, it requires

communicating the complex issues and medical information in simplified language that

can be understood by the patient’s families (Zazpe, 1996). In normal circumstances,

ICU nurses provide information about the initial diagnosis and treatment options. Yet

family members frequently approached nurses and other hospital staffs for additional

information or requests for further explanations and clarification. Therefore, good

communication is fundamental when communicating medical information between

medical staffs and patients, or their families. Good communication not only benefits

patients and their families, but can also benefit the physicians by decreasing stress,

improving relationships and efficiency. It is important to note that an information flow

is necessary to reduce uncertainty and emotional arousal of a crisis situation, and to help

families understand the unpredictable nature of the patient’s condition. Such dynamic

complex situations lend themselves to an Activity Theory analysis.

At the centre of the activity system (Figure 6.5), representing this research, is the core

activity triangle shown in Figure 6.3 and again in Figure 6.4; which shows the

mediating tools and the crisis care context of the ICU community. The outcome of this

core activity feeds into the main activity of the ICU, the treatment of the critically ill

patient.

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The top triangle in Figure 6.5 illustrates the WBIS, which is a primary tool for the

core activity (communication) in this system. The model notes that this tool

supplements face-to-face interaction and the secondary tools of the medical knowledge

of both groups in the communication activity. The WBIS has the potential to play an

important role in solving the problem of difficulties in communication with the public in

health care systems. In stressful situations, online health information services may help

meet a family’s needs, since written information provided through the website may ease

the understanding of ICU and other medical concepts and terms. However, there needs

to be a change in the ICU culture: as families now seem to be more satisfied with

information given to them verbally than by website information service, and ICU staff

members also see this as the way things are done.

It is anticipated that there will be a growing trend for families to gather information

about their family member’s illness from the Internet, or browse and read through

relevant material on their own. Health websites deliver easily understandable

information to family members who participate in medical decisions, and improve the

general knowledge about ICU operation and vocabulary. This new information could

broaden a family’s knowledge base, enabling them to make a better assessment of

whether their loved one was indeed receiving the best care. Understanding the

challenges to make this happen in ICUs comes from the implications of the bottom

section of the activity systems of Figure 6.5.

The bottom two triangles in the activity system of Figure 6.5 represent the two other

activities, those of the ICU staff and the families of critically ill patients. These two

activities have a confounding influence on the context for the core activity. These two

activities provide the community of the core activity, where there is a tension between

the various elements of the activities. While both sets of subjects (ICU staff and

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families) have the patient’s welfare at heart, they have very different feelings,

knowledge, language and experience of an ICU.

For instance, families of critically ill patients are often stressed, because of the patient’s

situation and confused about the complex technical and medical information (Byrne &

Heyman 1997). As such, they seek explanations and social support that enable them to

cope with the crisis situation and help them make the right decisions. Most families

attempted to develop relationships with healthcare professionals because they assume it

would help the patient (Hupcey 1998). However, the direct interaction between

clinician’s and family members in an intensive care unit will be limited.

In addition, family members and relatives seek information, explanations and

reassurance on a daily basis because they realize that their knowledge about their

patient’s medical condition is incomplete and that their needs for information can be

satisfied by the verbal communication with physicians or within the web information

system (Beisecker 1990). In addition, the written information is essential to reduce

family members’ anxiety and is helpful in answering their questions when they are

unable to get regular information from ICU nurses. Moreover, information was not

obtained exclusively from ICU staff, but also from the Internet. Families generally want

information on how their family member is doing, regardless of whether it is "good

news" or "bad news”.

ICU staff helps patients' family members understand what physicians are saying and the

relevance of that information for a patient's prognosis, decisions about treatment, and

also to deliver the bad news (McClement & Degner 1995 and Lee et al. 2002). Through

the analysis of the statements offered by the nurses working in an ICU, I concluded that

they view the communication with families as important. However, they face many

obstacles to communicating in such crisis situations where families may not have

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medical knowledge to understand the ICU environment. It is important to consider that

web-based information systems are the best method of creating and enhancing the

knowledge of people who need information in complex and crisis situations by

providing information to the user at the time it is required. However, from the point of

view of the ICU, parts of the information (patient’s medical conditions) can be

constantly changing, and the user needs (family) will be changing as the situation

develops, which requires a dynamic web based system providing information that can

be changed and updated.

In summary, all the activities illustrated by the Figure 6.5 are inter-related and influence

the final activity in the system, which is a patient’s health. The complex and conflicting

relationships in this activity system are at least identified in model Figure 6.5. This

research recommends providing verbal information, together with written or web-based

information, to assist in more effective communication between intensives and families

of patients, resulting in a higher quality health care service.

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6.5 CHAPTER SUMMARY

This chapter introduced the use of Activity Theory in this study and its applicability to

the study of communication in Intensive Care Units, between families and ICU staff

particularly, and in critical situations in general. As is identified in the literature,

effective communication between medical care staff (professional) and their patients’

family members (public) is a vital component of quality care (Ruiz-Moral et al. 2006;

Bhasale et al. 1998; and Coiera &Tombs 1998).

In the first attempt at this analysis, the ill health of the patient is the object of the core

activity in this case and the improvement of the patient’s health condition is the

intended outcome, which is the purpose (motive) of the activity. Communicating with

families and building alliances with them improves the health care outcomes for the

patient and provides the emotional support to the families to cope with this critical

situation, and they communicate with other medical staff to manage the care of a

critically ill patient. So, the core activity is the treatment of the patient. The community

of this activity consists of the patients, patient’s relatives, ICU clinicians and Health

Care professionals. Activity Theory approach allows access to the advice and guidance

from users on the additional growth path the Health Care Services can take for the

WBIS.

The second Activity theory analysis focuses on communication as a core activity. This

is meditated by primary, secondary and tertiary tools, as the group of subjects are using

different kinds of tools to communicate (face-to-face and WBIS). As shown in Figure

6.5, there is a complex environment for this activity due to differences between the

medical staff and the patient’s family, who are general members of the public. They are

communicating with medical care staff to ask about the patient’s medical situation, to

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reduce the uncertainty and reduce their anxiety and stress; involving patient care with

directions from the medical staff, and they are communicating with other family

members to exchange the information. There are many related factors that affect the

efficiency of the communication process: communication skills, professional language,

previous knowledge, multicultural translation problems and ICT.

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CHAPTER 7: RESEARCH DISCUSSION AND RESULTS

7.1 INTRODUCTION

This chapter presents the discussion of the findings and introduces the key conclusions

from this study. The broad focus of this study is to create a greater understanding of ICT

support for communication and information flows between professionals and the public

in crisis situations. More specifically, a study has been conducted of both face-to-face

and online information flows within ICUs through the collection, analysis and

modelling of data from different stakeholders.

The chapter is structured to present the following message. Firstly, the analysis of data

from three sets of stakeholders reveals multiple perspectives on communication issues

in ICUs, and the value of the WBIS. As it is difficult to get a meaningful and far-

reaching picture of this whole complex situation, System Dynamics and Activity Theory

are used to model the problem. Thus, in the second instance, this chapter discusses the

contribution and implications of these models. The discussion then opens up and

suggests more innovative approaches to this issue. The chapter concludes with outline

recommendations and suggestions for practical improvements to enable clinicians or

patients to traverse the WBIS and use information more efficiently.

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7.2 FINDINGS FROM THE DATA COLLECTED FROM

STAKEHOLDERS

The main messages from the three sets of stakeholders, as reported in chapter 4, are as

follows:

• State-based staff and web-site developers: Interviews and other consultation led

to the conclusion that they were of the belief that their web-based information

system facilitates effective dissemination of ICU information to all stakeholders.

WBIS helps deliver appropriate information to the relevant people, which

improves performance in the ICU and also helps patient’s families in medical

decision making. Although the WBIS is a secondary source of information, it

can facilitate effective communication between professionals and the public, and

reduce fear and stress amongst the patients’ families.

• Staff in the ICU units: Statements from the Q-study concourse indicate that web-

based information and images can possibly help families better understand the

patient’s situation and minimise complications with the communication process

between ICU staff and families in crisis situations. It is important to note that the

current web-based information system is not widely used for this purpose.

• The patients’ relatives and general public: Activity-based usability tests of the

website found that family members could easily access the relevant information

from the WBIS. It helps patients' families to gain a better understanding and

reduces the patients' families’ psychological stress and fear because their relative

is in a critical condition. This leads to better care for their patients and also more

understanding of the nature of ICU work. It may also assist the families in

sharing important decisions made by the doctors and ICU workers about the

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health of their patient. However, in critical situations, they prefer verbal

communication to be able to discuss the patient’s condition face-to-face with the

clinicians.

Section 3.3.3 in Chapter 3 illustrates the importance of getting useful primary data from

the family members of patients in an ICU. This was a particular challenge that was met

through the use of simulating realistic scenarios in a Usability Laboratory. For ethical

and logistical considerations, it was decided not to attempt to get primary data from the

families of patients in ICUs. As the website is public and all members of the public are

potential users, a simulated approach was decided upon. Data on this group of

stakeholders was gathered using Activity-based usability tests replicating the ICU

situation in a Usability Laboratory.

Information needs are very important for family members; this finding reinforces results

from previous studies (Molter 1976; Leaske 1986; Norris & Grove 1986). As expected,

families are more satisfied with information given to them by ICU staff than by a web-

site information service. However, the ICU staff can appreciate its use in assisting them

with the communication process. There is, however, a need for further awareness of

ICU clinicians to see the potential of web based information to enhance their interaction

and communication with family members, in order to both meet their information needs

and to help them to cope with the stress and anxiety associated with ICU settings

(Azoulay et al. 2003; Hughes et al 2004, and Azouly et al. 2005).

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7.3 FINDINGS FROM THE SYSTEMS AND ACTIVITY

MODELLING

System Dynamics and Activity Theory were used to model the problem to overcome the

difficulties in getting a meaningful and far-reaching dynamic picture of this whole

complex situation.

It is important to consider that web-based information systems is an increasingly

relevant method of creating and enhancing the knowledge of people who need

information in complex and crisis situations by providing information to users at the

time it is required. However, in the ICU situations, much of the information related to a

patient’s medical conditions can be constantly changing and the user needs – the family,

will be changing as the situation develops.

This study demonstrates that using SD modelling provides an insightful understanding

of information flows and knowledge transfer in crisis and complex situations. This is

especially shown in ICUs where family members need information to cope with

stressful times and ICU staff members are not always able to communicate effectively.

Different types of communications, face-to-face or web-based, are instrumental in

achieving high quality healthcare for patients and their families. While face-to-face

contact is crucial, the systems model acknowledges the value of online supplementary

information that is compiled by experts in suitable languages and presentations made

available publicly on the Internet.

7.3.1 The System Dynamics Model

As described in Chapter 5, the starting point for building the a conceptual model was

simply mapping the key stakeholders, in this case, ICU staff and family members;

following a review of the literature, the collection and analysis of primary data from the

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various stakeholders. Findings from the data analysis support the on-going evolutionary

development of a SD model using the stock and flow techniques of Stella software.

SD modelling is a general technique used to imitate, on computers, systems exhibiting

complex, time-dependent behaviour (Sterman 2000). In this case, a model was created

to simulate the information flows and accumulation of understanding during critical

situations of patient care in the ICU. Models can be used to investigate the system

without disrupting the real activity; a very important issue in the work of an ICU. It is

possible to replicate complex patterns of behaviour and gain insight about the

interaction of variables in dynamic and holistic way that are not achievable in the

traditional reductions and objective approaches to research.

An aim of this phase of the study is to model the type of communication that takes place

in complex stressful settings, such as in intensive care units, using the stock-flow

modelling technique. The results demonstrate the value of this technique for visualising

the entire system, identifying its element and relations between them. This researcher

would be able to manipulate these elements and relationships through the model to gain

an understanding of the dynamics of the situation and determine future directions for the

investigation. The use of SD modelling has been shown to be valuable in facilitating

discussion among disparate groups of stakeholders, in this case the researchers, health-

care professionals, government health administrators and end users of the website.

The modelling process shows simple types of information flows between two people;

one represents relatives of patients in ICUs who want information on how the patient is

doing. Whether there is “good news” or “bad news” is affected by a number of factors:

his current medical knowledge, stress level related to riskiness of the patient’s situation,

etc. On the other hand, ICU nurses represent face-to-face communication, and web

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information represents written communication, which affects the information quality

and informing process.

The conceptual model presented in Chapter 5 is based on a literature review, and the

analysis of the data collected from the three sets of stakeholders: members of the state-

based ICU Coordination Unit, responsible for the web-site; the ICU clinicians, and

surrogate family members.

This conceptual model represents:

• Family members’ need for information about the patient’s condition and general

medical information about the ICU.

• ICU staff (administrators/nurses/physicians) support relatives of patients through

giving them necessary information in a digestible form and with answers to their

questions.

• The web information service provides general written medical information about

ICU procedures and equipment in the state hospitals, as this online service

facilitates communication between and among the state’s regional ICUs so that

information is shared between clinicians, patients, their families and the

community.

7.3.2 The Activity Theory Model

Activity Theory provides this study with a means to examine the expressed and

evaluated views in a framework that focuses on the main activities of the

communication and the purpose for which information is used. Activity as the unit of

analysis has the core subject-object relationship, which is doing what supported and

enabled by the tools they use. An activity includes motive and purpose; the community;

the historical and social context; the physical and psychological tools; and, most

importantly, emphasises the relationship between various aspects of the activity.

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In Chapter Six this researcher used Activity Theory as a framework to present and

analyse the complex and dynamic communication system in an ICU setting. It begins

with the core activity concerning patient health but recognises that most of the visible

activity in an ICU is undertaken by others, principally the clinicians but also the

patient’s family and the builders of the supporting WBIS.

Activity Theory has been a useful framework in analysing human behaviour in this

study. Since there are many research approaches to study human behaviour, and

modelling of complex situations, they often neglect the social and cultural factors and

ignore the core activity of the situation. Activity Theory provides explanations of how

and why the professionals communicate with the public, and how they use the

computing tools to help manage the relationship between their institutions and the

public.

7.4 DISCUSSION OF MAIN FINDINGS

The literature presented in Chapter 2 supports the assertion that health services

outcomes can benefit from better communication and information systems. However,

there are challenges in their development due to a lack of holistic knowledge about such

systems, a shortage of suitable resources such as technical, financial and human resulted

discrepancies in language and culture between the medical professionals and public.

Creating effective WBIS for such environments need to understand the impact on

communication of different modes of information flows between professionals and the

public under conditions of crisis and stress.

This thesis, therefore, takes an innovative research approach to address the problem of

how professionals inform and communicate effectively with relevant members of the

public in high-stress situations. A multifaceted study of information flows in hospital

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Intensive Care Units is used to highlight the role of web-based technologies in

providing information to support professional–public communication.

In the initial phases of the research, qualitative data was collected from different sets of

stakeholders using appropriate techniques. In the latter phases of the research, models

were used to represent the communication in complex settings in the healthcare system,

that is, intensive care units.

As described in Chapter 4, the Intensive Care Coordination and Monitoring Unit

(ICCMU)4, is a division within the New South Wales (NSW) Health department,

established to provide centralised information resources to ICUs and interested

members of the public across the state. The aim of their service is to provide Web-

Based Information System (WBIS) to relatives of patients and clinician so they can

access and retain valuable information. They assume that the WBIS is achieving its

goals, which are centred on providing effective communication and interaction methods

to its stakeholders through its WBIS. In regard to the management of care and the

clinical information system, they hope the WBIS will have a significant impact on

reducing cost, improving quality of healthcare, and help eliminate and prevent

medication error (Coiera & Tombs 1998 and Anderson 1997).

As discussed in Chapter 2, there are an increasing number of people who communicate

and interact through the Internet to gather and exchange information, experiences and

find electronic emotional support groups.

The web gained its popularity from its ability to use text, graphics and sounds, as the

use of the Internet is based on individual requirements. Doctors mostly use simple

modes of communication such as emails to interact with their patients and colleagues.

To facilitate the use of online services, many organisations and academic institutions 4 http://www.Health.nsw.gov.au/iccmu

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provide email accounts for both medical practitioners and the public. WBIS connects

patients with healthcare providers by secure e-mail or Internet-based video consultations

(Kiser 2001; Lewis 2000 and Bylund 2007).

Internet usage has significantly grown across all sectors, primarily as an information

resource, with the shift toward electronic information in health services. In time,

patients will eventually have access to a variety of clinical information such as

medication schedules, online information sources and contacts details for clinics.

Patients in the future will be required to integrate, organise and coordinate their health

service requirements. Patients are likely to receive medical updates and information. It

would be the responsibility of the patients to monitor their own health and consult a

medical practitioner (Anderson 1997 and Norum et al. 2003).

As described in Chapter 2, it is well known that families of critically ill patients are

often stressed because the situation, and confused because the complex technical and

medical information. Therefore, they ask for explanations and need social support that

enables them to cope with this crisis situation and to make the right decisions, especially

for the end of life decisions (Hughes et al. 2004, Lloyd & Bor 2004, Zazpe 1996 and

Azoulay et al. 2000).

Data analysed in this study confirms this, with experiences in ICUs of suffering family

members of critical ill patients needing to receive positive support from ICU nurses.

As identified in Chapter 4, WBIS has the potential to provide relevant information to all

stakeholders besides improving the performance in ICUs. In crisis and stressful

situations, online health information systems provide the family need for written

information in a way that is easy to understand. However, verbal communication in

addition to written or web-based information is also necessary for more effective

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communication between ICU’s staff and families of patients, resulting in a higher

quality health care service.

All participants in this study agreed that there is a need for using information

technology and communication tools to enhance and improve communication,

understanding and management of health information to foster the relationships among

the health system and its environments, and to enhance and improve all aspects of

patients care. The low level use of the ICCMU, as reported by those in the ICU, shows

that more needs to be understood to make such services effective.

As discussed in Chapter 2 and demonstrated in Chapter 6, the Activity Theory analysis

emphasises the inter-relationships between all relevant activities with connection to the

core activity of interest. From the ICU perspective, as shown in Figure 6.5, the core

activity of interest is the treatment of the patient with communication existing as a

supporting tool. This perspective is supported in the literature, which says that effective

communication between medical care staff (professional) and their patients’ family

members (public) are vital components of quality care (Burke, et al. 2004 Ruiz-Moral et

al. 2006; Bhasale et al. 1998; Brannon & Bucher 1989; Coiera & Tombs 1998).

From the applied perspective, it is important to consider how web-based information

systems can create and enhance the knowledge of people who need information in

complex crisis situations, at the time it is required (Johnson 1990; Larson 1999). Family

members and relative seek information because they realise that their knowledge about

their patient’s medical condition is incomplete. In the ICU situation, information

relevant to the patient’s medical condition is constantly changing.

For this type of research, the SD modelling approach and Activity theory are shown to

provide holistic and dynamic ways to investigate such complex socio-technical

phenomena. The model can provide an analysis that creates a balance between face-to-

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face communication and the provision of information electronically – and how this

balance is affected by the stress on the family due to the critical nature of the patient’s

condition. Factors such as the medical and communications skills of ICU clinicians, the

medical knowledge level of the family members and the quality of the website can all

be investigated using this approach.

This research shows that information delivery for family members of patients receiving

critical care and terminal diseases need to be individualised with particular attention to

process at all stages of the illness. Families use secondary sources of information to

complement and verify information given by medical health professionals. The

interactive design is about maximising the capacity in which people work, communicate

and interact, creating user experiences and indicating possibilities to support people

(Preece et al. 2002).

In an effort to increase awareness of public health, web sites and the Internet

conveniently fulfil the purpose. The WBIS should be designed for easy use, and where

possible, be fun and interesting to use.

It is important to analyse the intended users of the system in order to better understand

their needs and perceptions that will help ensure the effectiveness of the communication

with the target group, because each group differs in how and where they access health-

related information.

The WBIS should provide and promote excellence in the standards of care, improving

the provision of accurate information and enhancing communication.

7.5 CHAPTER CONCLUSION

In conclusion, this study identifies the nature and types of communication between

healthcare providers and public, using a number of qualitative research methods to

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understand the nature of communication in crises situations to identify the information

needs of family members of critical care patients.

The findings of this study are also relevant in other areas outside health services that

also involve communication between professionals and the general public. This study is

the first that represents a simple model for the nature of communication in large and

complex systems using one type of SD modelling that creates more understanding of

information flows, and shows how nurses recognise the families’ needs to receive

information through personal or written communication.

Therefore, the following conclusions can be made from this study:

- Communication between the public and professionals in crises situations is

complex due to various factors that limits effective communication processes.

This study identified the factors that affect communication. However, as the

communication process is dynamic, the factors may evolve over time. Therefore,

it is an important responsibility of service providers to use advanced

technologies that support and facilitate effective communication between the

public and professionals.

- The usability test applied to the health care websites in this study reveals a

number of recommendations that are consistent with previous studies in HCI.

The crux of web-based information systems is user information needs, which

provide guaranteed user satisfaction.

- More importantly, although online information services are already being used

to inform the public, it is necessary to continue the online services with

technological advancement to ensure effective exchange of communication

within the desired timeframe betweens users and provides.

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Finally, this study concludes that advanced technology has a significant impact on

communication and on making important decisions by reducing stress and anxiety

during crises situations in such environments as in intensive care units.

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CHAPTER 8: IMPLICATIONS OF THE RESEARCH

8.1 INTRODUCTION

This final chapter begins with a review of the study of ICT supported communication in

ICUs and its results. It then discusses the contributions of the study in the context of the

broader topic of professional public communication in crisis environments. This chapter

also critically examines the benefits of the novel research techniques used in the study.

The chapter concludes with the limitations of the study and opportunities for future

research.

8.2 REVIEW OF THE STUDY AND RESULTS

The research problem brings a greater understanding of ICT support for communication

and information flows between professionals and the public in crisis situations. This is a

common problem in the field of health, but also a current issue in planned responses to

critical incidents such as man-made or natural disasters. The crisis environment of the

ICU provides a particularly challenging environment for professional-public

communication, and so is a suitable site for this investigation.

This study is of relevance to issues of ICT in healthcare from two perspectives. Firstly,

the focus of the study is on the use of the Internet to provide information that can assist

the communication processes in ICUs concerning patients’ wellbeing and treatment.

Secondly, it shows how ICT applications, Stella modelling, Activity Theory, Q-

methodology, Zing groupware and Usability Testing can be used to support research in

this complex area when collecting and analysing data is complicated by access and

ethical issues. The study, evaluated from a user’s perspective, shows the evolving

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Online Heath Information Services that are provided by a government ICU coordination

and monitoring unit in NSW.

This research was conducted in order to understand the nature of ICT supported

communication between family members of critically ill patients and intensive care unit

staff members as a representative of crisis situations where there is an urgent need for

professional experts to communicate with the public. The majority of this

communication concerns the objects of a critical activity, in this case the patients’

medical condition and treatment. Models are used to depict the various factors and

relationships surrounding the use of traditional verbal communication, which is

supplemented by communication that occurs via a website developed by a state ICU

Coordination Unit.

A qualitative research approach was selected for the data collection from three

stakeholder groups in the study; firstly, by interviewing the management of a website

about the development and rational of the WBIS; then a Q methodology concourse

using Zing groupware was adopted to evaluate the online health information from the

perspective of ICU staff; and after that, usability tests were carried out to investigate the

information needs of family members of critically ill patients using the online health

information service.

A conceptual System Dynamics model was developed in an evolutionary fashion;

informed by a review of the literature, as well as the collection and analysis of data from

various stakeholder groups. The modelling process used Stella systems modelling (ISEE

Systems 2006) to explore and display the issues in a holistic way to understand the

dynamic nature of communication in ICU. Reflection by researchers, together with

feedback from practitioners on each version of the model provides additional input for

the model’s continual improvement.

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While the development of the System Dynamics model extends the understanding of the

use of web-based information in crisis situations, such as those found in ICUs, it is

limited by the constraints of the stock-flow modelling framework. A deeper analysis of

the communication within the ICU used Activity Theory as a framework. Activity

Theory provides a particular definition of human activity that can be adopted as a unit

of analysis for research into complex situations such as those in the critical care

circumstances of an ICU. This approach to research works on recognizing and defining

an activity supported by its actions and operations. This consists of motivation, goals,

tools, object, outcome, rules, community and division of labour, which are considered to

be key elements of the holistic unit of analysis.

Two Activity-based models are developed. In the first, the ill health of the patient is the

object of the core activity, and the improvement of the patient’s health condition is the

intended outcome. The community of this activity consists of the patients, patient’s

relatives, ICU clinicians and Health Care professionals. Supporting activities are the

communication needs of the ICU staff members and the families of patients.

More relevant to this study, the second Activity-based model focuses on the

communication as a core activity. This is mediated by primary, secondary and tertiary

tools as the group of subjects are using different kinds of tools to communicate (face-to-

face and WBIS). There is a complex environment for this activity due to differences

between the medical staff and the patient’s family, who are general members of the

public. They communicate with medical care staffs to ask about their relative’s medical

situation to reduce the uncertainty and reduce their anxiety and the stress. They also

communicate with other family members and exchange information. There are many

related factors shown in the model that affect the efficiency of the communication

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process: Communication skills, professional language, previous knowledge, and

multicultural translation problems and ICT.

The conclusions based on the results are that there are complex relationships between

ICU staffs’ motives to communicate in medical terms and family members’ information

needs, where their anxiety in crisis situations affects their ability to communicate

effectively through traditional communication (face-to-face) and online health

information services. The study has produced models that assist in understanding the

dynamics of such situations in a holistic manner.

Further collaborative studies are encouraged to build System Dynamics and Activity-

based models to visualise different types of crisis situations, particularly those using

interactive ICTs. This approach brings out issues of information flows and core

activities which are often neglected.

This study is the first that represents a simple model for the nature of communication in

large and complex systems using modelling, which can be useful to gain more

understanding of information flows and how the nurses recognize the families’ needs to

receive information through personal and/or written communication.

In summary, the informational needs of relatives of ICU patients have been studied

extensively in studies of families in critical care settings, so it is an important topic. This

study adds to the knowledge in this area using a dynamic Stock-Flow model that

represent the two types of information flows between families and nurses and Activity

Theory to better understand the full context of families’ experiences of communications

available within current ICU systems

This study aims to provide a greater understanding of how information technologies can

be used to resolve problems that arise with the ad-hoc, face-to-face communication that

currently occur in this area. To underpin the research, a SD model of information in an

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ICU was developed in an evolutionary fashion using Stella software, and then extended

with an activity-based framework to put the communication in perspective of the main

purpose of the stakeholders’ activities. This study thus creates deep knowledge about

the nature of communication in crisis situations. This study shows a clear interest in the

provision of a web-based support service for critical ill patients that provides general

health information and explanations of medical terms.

These findings will inform all those creating similar web-based ICT systems to provide

critical information to the public.

8.3 CRITICAL SUMMARY OF THE INNOVATIVE RESEARCH

TECHNIQUES USED

In order to provide a fresh perspective on the research problem, innovative research

techniques were adopted. The benefits of these are now discussed.

8.3.1 Q-Methodology Concourse using Zing Groupware

In this study, a Q-method concourse is used for data collection from ICU administrators

and clinicians, on their subjective views of the situation, from representative hospitals

across the state. Q methodology was adopted because it provides one of the most

developed methodologies for the collection and analysis of individual understandings of

an experience or a topic. It does not presuppose issues in the way a survey does, but

aims to encourage participants to come up with all issues relevant to the topic.

According to Meloche (1999), Q methodology provides a standard set of procedures for

analysing qualitative data by eliciting the subjective understandings held by

participants. The source of the data is frequently based on individual viewpoints about a

particular topic, view or event (Meloche et al. 2005).

194

The first part, the Concourse, occurs in a social context to generate as many statements

on the subjects or topics as possible that express the participants’ understandings of the

topic or the subject. In Q methodology, subjects are asked to consider a set of

statements on a topic that they may have generated, and to arrange them in an order that

reflects their view of the statements, usually from strongly disagree to strongly agree.

This process is called a Q sort. The sorts are then analysed and interpreted to produce

models of sets of views on the topic.

In this study, the statements gathered from a series of concourses with ICU staff

members on their attitudes to, and suggestions for, the WBIS, provide rich data.

8.3.2 Usability Testing

The usability testing approach was used in this study in Chapter 3 and Chapter 4, as it is

an important tool in human-computer interaction communities to collect data from the

end-users that can result in more effective decisions to develop and improve web-based

information services. In Chapter 3, this study highlights the importance of the usability

and its crucial role in the success of computer-based information systems. In Chapter 4,

the findings and recommendations are identified in detail with lists of usability

evaluation improvements to address the current problems in this case study web-based

information system, from the view of families, as one of the end-user groups. This

resulted in rich and realistic data from their perspective as an alternative to interviews

with people in ICUs, which would have been difficult for ethical and logistical reasons.

8.3.3 System Dynamics Modelling

This approach of SD modelling can be used to give a contextual and holistic

understanding of knowledge transfer in similar crisis situations, which are difficult to

research by more direct means.

195

This study is groundbreaking in the use of SD modelling to study the nature of

communication in critical complex systems such as those found in the ICU. It

demonstrates the usefulness of SD modelling as a research tool whereby both

researchers and participants’ understanding of the issues are enhanced through the

modelling process. The model provided a means of re-interpreting the data,

encapsulating the knowledge gained from the study and visualising the research

findings in an innovative way that enables the project to move forward.

The results of the study indicate that using SD modelling provides an insightful

understanding of information flows and knowledge transfers in crisis and complex

systems. The development of the models has allowed us to extend our understanding of

the use of web-based information in crisis situations, such as those found in ICUs.

SD modelling is used to explore and display the issues in a dynamic and holistic way to

understand the nature of communication in ICUs. Models are used to depict the use of

traditional verbal communication and are supplemented by communication that occurs

via a website developed by a State ICU Coordination Unit.

8.3.4 Analysis using an Activity Theory Framework

This study applied the Activity Theory to provide means to examine the expressed and

evaluated views in a framework that focuses on what people are really doing and

includes the community, the cultural-historical context, and the tools which included not

only primary, physical artefacts but also secondary tools such as the specific type of

language used by experts in a particular field.

The Activity Theory analysis emphasises the inter-relationships between all relevant

activities with identification of the core activity of interest. From the ICU perspective,

the core activity of interest is the treatment of the patient, with communication as a

196

supporting tool. The research emphasised communication as the core activity of interest

and developed an activity-based model showing all elements of this activity system

(Figure 6.5).

Activity Theory is an approach to conceptualize relationships between individuals,

communities, technologies and activities that consider the tool to be mediating the

human interaction with the world (Kuutti, 1999).

8.4 LIMITATIONS OF THE STUDY

The one strength but also a limitation of this study is considered to be its qualitative

method, e.g. collecting data directly from the families of ICU patients. Qualitative data

give depth and insight which is important in a dynamic, complex context but does not

allow the full capability of SD modelling to actively depict the information flows.

Another strength but also limitation of the study is it breadth at the expense of focus.

Data was collected from a range of stakeholders using different exploratory methods.

8.5 THE THEORETICAL AND PRACTICAL CONTRIBUTIONS

This study makes significant theoretical and practical contributions regarding online

professional-public communication and web-based information services. The theoretical

research contributions of this study are as follows:

8.5.1 Research Contribution 1

This study highlights the importance of online information services for experts to

communicate with the public, particularly in economically and structurally advanced

countries like Australia. The findings, however, show that it is difficult to do this well,

and that initial attempts may not meet the needs of the intended users and hence not be

well used.

197


This thesis demonstrates the value of a mix of innovative research methods in

contemporary information systems, due to the fact that traditional research approaches

are no longer sufficient to meet the growing complexities of this area. This raises the

need to be more innovative in the methods used for this type of research, which aims to

understand the various dynamically interconnected elements. This is a challenge, but

should not deter the conduct of this type of research and should create significant

opportunities provided by new forms of ICT, such as the one addressed in this thesis.

The research approach taken in this thesis acknowledges the complexity of the situation

in an ICU and the interrelationship of constantly changing organisational, human and

technical elements in a stressful context. In addition to information from the literature,

data is collected and analysed from three sets of ICU stakeholders (clinicians, families

of patients, State Health Department website owners) using three different techniques

suited to the context of the stakeholders. The results of this analysis feed into an

evolutionary system modelling process, which both integrates the data and literature,

and also dynamically visualises the information flows between the different

stakeholders. The resulting model is then qualitatively reinterpreted using concepts and

frameworks from Activity Theory in order to provide deeper insights into the

relationships within the system.

These include the use of Q-methodology and Usability testing for data collection, the

use of Stock-flow modelling to investigate communication for explaining the nature of

information flows in dynamic complex and stressful environments, and the use of

Activity Theory to provide a deep holistic interpretation of the models.

198


The research contribution of this study derives from the development of conceptual

models for explaining the nature of communication in complex and stressful

environments.

Most importantly, this research provides a holistic understanding of communication

between professionals and community, which includes an online component.

This research takes a comprehensive and inclusive view of the complex issues of

communication that exist between healthcare providers and the family members of

critically ill patients in the dynamic and high stress environment of ICU (Auerbach et al.

2005 & Azouly et al. 2003). It addresses efforts to support face-to-face information

exchanges with material put together in a language that the general public can

understand, by experts in this area, on a public website.

8.5.3 The Practical Contribution


improving Health Care Web-Based Information delivery in Intensive Care

Environments.

This study gives perspective the beneficial role of secondary information sources such

as the Internet, when professionals failed to give enough information in understandable

language. Internet sources provide alternatives and can help inform decision-making.

This study showed a clear interest in the provision of a web-based support service for

critically ill patients that is important for providing general health information and

explanation of medical terms.

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8.6 THE OPPORTUNITIES FOR THE FUTURE STUDY

The most significant suggestions for improvements to the existing WBIS were to have

more interactive facilities on the site and a means for families to get specific

information on their patient. Research is needed into the ramifications of this,

particularly from legal and technical perspectives. Further research is also needed to

model the communication in ICU settings between groups of people, in order to give

more understanding of the information flows and examine the satisfaction and

expectations of families of ICU patients and those of the ICU team.

In addition, further research into difficult communication situations within the health

care system is required to develop best practice in this area.

Further collaborative studies are encouraged to build SD models to simulate information

and knowledge flows in different types of crisis situations, particularly in health care.

One could redesign the usability test with families to include a simulation of the verbal

interaction, with someone playing the role of the clinician in conjunction with the video.

As this study creates knowledge about the nature of communication in crisis situations,

in future research the approach and results of this study could be used to examine issues

concerned with the use of the Web for information flows, knowledge transfer,

understanding and learning in different types of crisis situations, which cannot easily be


200

REFERENCES

Althaus, S. & Tewksbury, D. (2000). Patterns of internet and traditional news media use in a networked community. Political Communication 17(1), 21 – 45.

Andersen, D.F., Richardson, G.P. & Vennix, J.A.M. (1997). Group model building: adding more science to the craft. System Dynamics Review 13, 187-201.

Anderson, J.G., Harshbarger, W.H., Weng, H.C., Stephen J.J. & Marilyn M.A. (2002). Modelling the costs and outcomes of cardiovascular surgery. Health Care Management Science 5(2), ABI/INFORM Global pg. 103.

Anderson, J.G. (1997). Clearing the way for physician’ use of clinical information systems. Communications of the ACM 40(8), 83-90.

Auerbach, S., Kiiesler, D., Wartella, J., Rausch, S., Rware, K. & Ivatury, R. (2005). Optimism satisfaction with needs met, interpersonal perceptions of healthcare team, and emotional distress in patients’ family members during critical care hospitalization. American Journal of Critical Care 14(3), 202-211.

Azoulay, E., Chevret, S., Leleu, G., Pochard, F., Barboteu, M., Adrie, C., Canoui, P., Le Gall, J.R. & Schlemmer, B. (2000). Half the families of intensive care unit patients experience inadequate communication with physicians. Critical Care Medicine 28, 3044–49.

Azoulay, E., Pochard, F. & Chevert, S. (2003). Family participation in care to critically ill: opinions of families and staff. Intensive Care Medicine 29, 1498-1504.

Azoulay, E., Pochard, F., Kentish-Barnes, N., Chevret, S., Aboab, J., Adrie, C., Annane, D., Bleichner, G. and Bollaert, P. et al. (2005). Risk of Post-traumatic Stress Symptoms in Family Members of Intensive Care Unit Patients. American Journal of Respiratory and Critical Care Medicine 171, 987-994.

Baca, B. & Cassidy, A. (1999). Intranet Development and Design that Works. Human Factors and Ergonomics Society Annual Meeting Proceedings, Internet (pp. 777-781), Houston, TX (US).

Bagian, J., Lee, C. & Gosbee, J. (2001). Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about.The Joint Commission Journal on Quality Improvement 27(10), 522–532.

Bagian, J. (2001). Promoting patient safety at VA: Learning from close calls. Forum, VA: Health Services Research & Development 1, 2–8.

Baillie, L., Benyon, D., Macaulay, C. & Petersen, M.G. (2003). Investigating design issues in household environments. Cognition, Technology & Work 5(1), 33-43.

Baker, T.L. (1994). Doing social research. McGraw-Hill Inc, New York.

Bankes, S. (1993). Exploratory Modeling for Policy Analysis. Operations Research, 41, 435-449.

http://www.ingentaconnect.com/content/hfes/hfproc;jsessionid=1cq40cohk8qgu.alexandra�

http://www.ingentaconnect.com/content/hfes/hfproc;jsessionid=1cq40cohk8qgu.alexandra�

201

Banks, J. (2000). Introduction to simulation. In Proceedings of the 2000 Winter Simulation Conference (Eds.), J.A. Joines, R.R. Barton, K. Kang, and P.A. Fishwick, (pp. 9-16).

Bannon, L., & Bødker, S. (1991). Beyond the interface: encountering artefacts in use. In J.M. Carroll (Ed.), Designing interaction: psychology at the human computer interface (pp.227-253) Cambridge University Press, Cambridge, UK.

Bannon, L. (1997). From human factors to human actors: the role of psychology and human computer interaction studies in system design. In J. Greenbaum and M. Yng (Eds.), Design at work: cooperative design of computer systems (pp. 25-44) Lawrence Erlbaum & Associates, Hillsdale, NJ.

Barfiled, L. (1993). The User Interface Concepts & Design. Amsterdam, Addison- Wesley Lawrence Erlbaum.

Barkly, M. (1975). Adaptation of the Q-Sort Technique as an Evaluation Device. Illinois Teacher of Home Economics 38(4), 206-207.

Barlas, Y. (1996). Formal aspects of model validity and validation in system dynamics. System Dynamics Review 12(3), 183–210.

Barnes, C.D. & Quiason, J.L. (1997). Success stories in simulation in health care. In S. Andradóttir, K.J. Healy, D.H. Whithers and B.L. Nelson (Eds.), Proceedings of the 1997 Winter Simulation Conference (pp. 1280-1285) Association for Computing Machinery, New York, NY.

Beckman, H.B., Markakis, K.M., Suchman, A.L. & Frankel, R.M. (1994). The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Archives of Internal Medicine, 154(12), 1365-1370.

Beilner H. & Stewing, F.J. (1987). Concepts and techniques of the performance modelling tool HIT, in: Proceedings of the European Simulation Multiconference, Vienna, SCS Europe.

Beisecker, A.E. (1990). Patient Power in doctor-patient communication: What do we know?. Health Communication 2, 105-122.

Bernnan, P. (1996b). Computer networks: new tools for nursing practice. Applied Nursing Research 9(4), 159-160.

Bertalanffy, V. (1967). Robots, Men, and Minds; Psychology in the Modern World. New York: Braziller.

Bertalanffy, V. (1968). General system theory: foundations, development, applications. New York: Braziller.

Bhasal, A., Miler, G. & Reid, S. (1998). Analysis potential harm in Australian general practice: an incident-monitoring study. MJA169, 73-76.

Bias, R.G. & Mayhew, D.J. (Eds.) (1994). Cost-Justifying Usability. Academic Press Professional.

Bijtteber. P., Vanoost, S., Delva, D., Ferdinande, P. & Frans, E. (2001). Needs of relatives of critical care patients: perceptions of relatives, physicians and nurses. Intensive Care Medicine 27, 160-165.

Bimber, B. (1999). The Internet and Citizen Communication With Government: Does the Medium Matter?. Political Communication, 16(4), 409 -426.

202

Blanton, T. & Blach, D.C. (1995). Telemedicine: the health system of tomorrow. The Futurist 29, 14-17.

Block, SD. (2000). Assessing and managing depression in the terminally ill patient. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians—American Society of Internal Medicine. Ann Intern Med 132, 209-218.

Bødker S. (1990). Through the Interface: a Human Activity Approach to User Interface Design, Hillsdale, NJ, Erlbaum.

Bodker, S. (1991). Through the Interface - A Human Activity Approach to User Interface Design. Lawrence Erlbaum Berry, W. and Lewis-Beck, M.) Sage.

Boisot, M. & MacMillian, I. (2001). Simulating knowledge flow: An agent based modelling approach to social learning processes. Available at: www.research.smu.edu.sg/wsrc/pdfs/MBoist-IMacmillan_ SimulateKnowledge.pdf.

Boland, R. & Tenkasi, R. (1995). Perspective Making and Perspective Taking in Communities of Knowing .Org Science 6(4), 350-372.

Bouman, C. (1984). Identifying priority concerns of families of ICU patients. Dimensions of Critically Care Nursing 3(5), 313-319.

Brailsford, S.C., Lattimer, V.A., Tarnaras, B. & Turnbull, J.C. (2004). Emergency and on-demand health care: modelling a large complex system. Journal of the Operational Research Society 55, 34–42.

Brown, S.R. (1980). Political subjectivity: Applications of Q methodology in political science. New Haven, CT: Yale University.

Brown, S.R. (1986). Q technique and method: Principles and procedures. In W.D. Berry and M.S. Lewis-Beck (Eds.), New tools for social scientists (pp. 57-76) Beverly Hills, CA: Sage.

Buller, M. & Buller, D. (1987). Physicians’ communication style and patient satisfaction. Journal of Health and social behaviour 28, 375-388.

Burr, G. (1998). Contextualizing critical care family needs through triangulation: An Australian study. Intensive & Critical Care Nursing 14(4), 161-169.

Burr, G. (2001). Reaktioner och relationer inom intensivva°rd –na¨ rsta°endes behov och sjuksko¨ terskors ka¨nnedom om behoven [An analysis of the needs and experiences of families of critically ill patients: the perspectives of family members and ICU nurses] Studentlitteratur: Lund.

Byrne, G. and Heyman, R. (1997). Understanding nurses’ communication with patients in accident and emergency department: affecting quality and cost. Hospital Material Management Quarterly 16, 63-75.

Calder, B., Phillips, W. & Tybout, A. (1981). Designing research for application. Journal of consumer research 8, 197-207.

Carroll, J.M. & Carrithers, C. (1984). Training Wheels in a User Interface. Communications of the ACM, 27, 800-806.

http://www.research.smu.edu.sg/wsrc/pdfs/MBoist-IMacmillan_�

203

Carroll, J.M., Kellogg, W.A. & Rosson, M.B. (1991). The Task-artefact cycle. In J. Carroll (Ed.), Designing Interaction: Psychology at the Human-Computer Interface. Cambridge University Press.

Carroll, J.M. (Ed.) (1991). Designing Interaction, Psychology at the Human-Computer Interface. Cambridge University Press, Cambridge, UK.

Centeno, M.A. (1996). An introduction to simulation modeling. In Proceedings of the 1996 Winter Simulation Conference (Eds.), J.M. Charnes, D.J. Morrice, D.T. Brunner and J.J. Swa”n, (pp. 15-22).

Chan, Q. (2001). Human computer interaction: Issues and challenges. Ideal Group

Charles, S.C. & Lazarus, J.A. (2000). Reframing the professional ethic: the Council of Medical Specialty Societies consensus statement on the ethic of medicine. Western Journal of Medicine 173(3), 198-201.

Checkland, P. (1981). Systems Thinking, Systems Practice. Chichester, Wiley.

Checkland, P. and Scholes, J. (1999). Soft Systems Methodology in Action. Chichester, Wiley.

Christiansen, E. (1996). Tamed by a Rose: Computers as Tools in Human Activity. In B. Nardi (ED.), Context and Consciousness: Activity and Human-Computer Interaction (pp. 175-198) MIT press, Cambridge. MA.

Christopherson, B. & Pfeiffer, C. (1980). Varying the timing of information to alter the pre-operative anxiety and postoperative recovery in cardiac surgery patients. Heart and Lung; 9, 855–861.

Clarke, M. & Oxman, A.D. (2003). Cochrane reviewers’ Handbook.4.2.0. Oxford: The Cochrane Collaboration.

Cline, R.J. & Haynes, K.M. (2001). Consumer health information seeking on the Internet: the state of the art. Health Education Research 16(6), 671-692.

Coiera, E. Tombs, V. (1998). Communication behaviours in a hospital setting: an observational study. BMJ 316, 673-677.

Coiera, E. (1997). Guide to medical informatics, the internet and telemedicine. London: Chapman and Hall Medical.

Coiera, E. (2002). Interaction design theory. International Journal of Medical Informatics 0, 1-18.

Coiera, E. (2003). Guide to medical informatics.2nd edition. London: Arnold.

Cooper, A. (1995). About Face: The Essentials of User Interface Design. IDG Books Worldwide.

Costanza, R. and Ruth, M. (1998). Using Dynamic Modeling to Scope Environmental Problems and Build Consensus. Environmental Management 22(2): 183-195.

Covell, D., Uman, G. & Manning, P. (1985). Information needs in office practice: Are they being met? Annals of Internet Medicine 103, 596-599.

Coyle, G. (1979), Management System Dynamics, John Wiley & Sons, Chichester.

Coyle, G. (1996), System Dynamics Modeling: A practical approach, Chapman and Hall,London.

204

Coyle, G. (2000). Qualitative and Quantitative Modelling in System Dynamics: Some Research Questions. System Dynamics Review 16(3), 225-244

Cummings, T. & Worley, C. (1997). Organisation Development and Change, 6th ed., South Western, Cincinnati, OH.

Dahlgren, P. (2005). The Internet, Public Spheres, and Political Communication: Dispersion and Deliberation. Political Communication 22(2), 147 – 162.

Daingerfield, M.A. (1993). Communication patterns of critical care nurses. New Brunswick: Rutgers, The State University of New Jersey.

Dangerfield, B. (1999). System dynamics applications to European health care issues. Journal of the Operational Research Society 50, 345-353.

Davis, R.H., Alexander, L.T. & Yelon S.L. (1974). Learning System Design: An approach to the improvement of instruction. McGraw-Hill, Inc.

Davis, R.H. & Davis, H.T.O. (1994). Modelling patient flows and resource provision in health systems. Omega International Journal of Management Science 22 (2), 123-131.

Davis, R. & Owen, D. (1998). New media and American politics. New York: Oxford University Press.

Deloitte, R. (2006). The Emergence of the E-health Consumer, available at: www.dc.com/obx/pages.phpf. (accessed 20 January, 2007).

DeMello, S. & Gardner, B. (1990). A powerful tool for healthcare management. The Healthcare Forum Journal 33(2), 27-33.

Demiris, G. (2006). The diffusion of virtual communities in health care: Concepts and challenges. Patient Education and Counselling 62, 178–188.

Dennis, K.E. (1986). Q Methodology: Relevance and application to nursing research. Advances in Nursing Science 8(3), 6-17.

Derrick, S., Winch, G., Badger, B., Chandler, J., Lovett, J. & Nokes, T. (2004). Evaluating the impacts of time-reduction legislation on junior doctor training and service. Proceedings of the International Systems Dynamics Conference.

Dix, A., Finlay, J., Abowd, G.D. and Beale, R. (2004). Human-Computer Interaction. England: Prentice Hill.

Doyle, J.K. and Ford, D.N. (1999). Mental Models Concepts Revisited: Some Clarifications and a Reply to Lane. System Dynamics Review 15(4): 411-415.

Dretske, F. (1997). Knowledge and the Flow of Information. MIT Press, Cambridge, MA.

Dumas, S. & Redish, C. (1994). A Practical Guide to Usability Testing. John Wiley & Sons.

Dwyer, J. (2005). Communication in business: strategies and skills. Pearson Education Australia.

Dyson, B. and Chang, N. (2005). Forecasting municipal solid waste generation in a fast-growing urban region with System Dynamics modelling. Waste Management 25, 669-679.

http://www.dc.com/obx/pages.phpf�

205

Eldabi, T., Irani, Z. & Paul, R. (2002). A proposed approach for modelling health-care systems for understanding. Journal of Management in Medicine16 (2), 170-187.

Eleftheriadou, Z. (2004). Communication with patients from different cultural backgrounds. In M. Lloyd and R. Bor, Communication skills for medicine (pp. 85-93). Churchill, Edinburgh.

Ellis, W.N. (2000). Community life-long learning centres. In R. Miller (Ed.), Creating Learning Communities: Models, Resources, and New Ways of Thinking About Teaching and Learning (pp. 14-21). Brandon, VT: The Foundation for Educational Renewal, Inc.

El-Masri, M. & Fox-Wasylyshyn, S. (2007). Nurses’ roles with families: Perceptions of ICU nurses. Intensive and Critical Care Nursing 23, 43—50.

Eng, T.R., Gustafson, D.H., Henderson, J., Jimison, H. and Patrick, K. (1999) .Introduction to evaluation of interactive health communication applications. Science panel on interactive communication and health. American Journal of Preventative Medicine 16(1), 10–5.

Engeström, Y. (1987). Learning by Expanding: an Activity-Theoretical Approach to Developmental Research. Helsinki: Orienta-Konsultit Oy.

Engestrom, Y. (1990). Activity Theory and Individual Social Transformation, Multidisciplinary Newsletter for Activity Theory 7(8) 6-17 Cambridge

Engeström, Y. (1992). Interactive Expertise: Studies in Distributed Working Intelligence. (Department of Education Research Bulletin 83). Helsinki: University of Helsinki, Department of Education.

Engestrom, Y. (1996). Perspective on Activity Theory, Cambridge University Press.

Engeström, Y. (1998). Reorganizing the motivational sphere of classroom culture: An activity-theoretical analysis of planning in a teacher team. In F. Seeger, J. Voigt and U. Waschescio (eds.), The Culture of the Mathematics Classroom (pp. 76 – 103). Cambridge: Cambridge University Press

Engeström, Y. (1999b). Expansive visibilization of work: an activity-theoretical perspective. Computer Supported Cooperative Work, 8, 63-93. 7-15. Cambridge, Massachusetts: The MIT Press.

Engstro¨m, A. & So¨ derberg, S. (2005). Close relatives in intensive care from the perspective of critical care nurses. Journal of Clinical Nursing 16, 1651–1 659

Epstein, M. & Olsen, A. (2001). Mental illness: Responses from the community. In G. Medows & B. Singh (Eds.), Mental Health in Australia. Melbourne., Australia: Oxford University Press.

Eysenbach, G. & Diepgen, T.L. (1999). Patients looking for information on the Internet and seeking teleadvice: motivation, expectations, and misconceptions as expressed in e-mails sent to physicians. Archives of Ermatology 135, 151-156.

Eysenbach, G. & Ko¨ hler, C. (2002). How do consumers search for and appraise health information on the World Wide Web? Qualitative study using focus groups, usability tests, and in-depth interviews. BMJ 324, 573–577.

Eysenbach, G. & Kummervold, P.E. (2005). Is Cybermedicine Killing You? : The story of a Cochrane disaster. Journal of Medical Internet Research 7(2), e21.

206

Eysenbach, G., Powell, J., Englesakis, M., Rizo, C. & Stern A. (2004).Health related virtual communities and electronic support groups: systematic review of the effects of online peer to peer interactions. BMJ 328, p.1166.

Eysenbach, G. (2000). Towards ethical guidelines for dealing with unsolicited patient emails and giving teleadvice in the absence of a pre-existing patient-physician relationship – systematic review and expert survey. Journal of Medical Internet Research 2 (1), e1, available at: www.jmir.org/2000/1/e1/index.htm (accessed 6 April, 2005).

Fone, D., Hollinghurst, S., Temple, M. et al. (2003). Systematic review of the use and value of computer simulation modelling in population health and health care delivery. J Public Health Med 25,325–35.

Ford, A. (1999). Modeling the Environment: An Introduction to System Dynamics Modeling of Environmental Systems. Washington, Island Press.

Forrester, D., Murphy, P., Price, D. & Monaghan, J. (1990). Critical care family needs. Heart & Lung: Journal of Critical Care19, 655-661.

Forrester, J.W. (1960). The impact of feedback control concepts on the management sciences. In: Collected Papers of J.W. Forrester (1975 collection), Wright-Allen Press: Cambridge, MA, 45–60.

Forrester, J. W. (1961), Industrial Dynamics, MIT Press, Cambridge MA.

Forrester, J. W. (1968), Principles of Systems, Wright-Allen Press, Cambridge, MA.

Forrester, J. W. (1969), Urban Dynamics, The M.I.T Press, Massachusetts Institute of Technology,Cambridge.

Forrester, J. W. (1971a), ‘Counterintuitive behavior of social systems’, Technology Review73(3), 52–68.

Forrester, J. W. (1971b), World Dynamics, MIT Press, Cambridge, Massachusetts.

Forrester, J. W. (1992), ‘Policies, decisions and information sources for modeling’, European Journal of Operational Research 59(42-63).

Forsythe, P. (1998). New practices in the transitional care centre improve outcomes for babies and their families. Journal of Perinatology 18, 13-18.

Fox, S. & Fallows, D. (2003). Internet health resources. Washington, D.C.: Pew Internet & American Life Project, 35.

Friedman, M. (1998). Family Nursing: Research, Theory, and Practice, 4th edn. Connecticut: Appleton & Lange.

Furse, H.D., Burcham, R.M., Rose, L.R. & Oliver, W.R. (1994). Leveraging the value of customer satisfaction. Journal of Health Care Marketing 14 (3), 16-20.

Gagliardi, A. & Jadad, A. R. (2002). Examination of instruments used to rate quality of health information on the internet: chronicle of a voyage with unclear destination. BMJ 324(9), 569-573.

Garcia, M., Centeno, A., Rivera, C. & DeCarlo, N. (1995). Reducing time in an emergency room via a fasttrack. In Proceedings of the 1995 Winter Simulation Conference (Ed.), C. Alexopoulos, K. Kang, W.R. Lilegdon and D. Goldsman (pp. 1048-1053). Institute of Electrical and Electronics Engineers, Piscataway, N.J.

207

Gilliam, A.D., Speake, W., Scholefield, J. & Beckingham, I. (2003). Finding the best from the rest: evaluation of the quality of patient information on the internet. Annals of the Royal College of Surgeon of England, 85(1), 44-6.

Goldschmidt, P.G. (2005). HIT and HIS: Implications of health information technology and medical information systems. Communications of ACM 48(10), 69-74.

Gordon, G. (1969). System Simulation, Prentice-Hall, Englewood Cli1s, NJ.

Gordon, S. (2000). User testing: how to plan, execute, and report on a usability evaluation. http://builder.cnet.com/webbuilding/pages/Graphics/Evaluation/. (Accessed12 September 2003).

Gould, E. & Hasan, H. (1995). An Activity Theory Approach to the HCI of Executive Information Systems. Proceedings of the East-West HCI conference in Moscow, July 29-38.

Gould, E. & Verenikina, I. (1996). An Activity Theory Approach to User Modelling, CHI’96, Workshop on User Models, Vancouver, Canada,

Gould, E. (1998). Psychological information systems frameworks: a contrast between cognitive science and activity theory. In H. Hasan, E. Gould and P. Hyland (Eds.) Information Systems and Activity Theory: Tools in Context (pp. 39 – 58). Wollongong, University of Wollongong Press

Gould, J.D. & Lewis, C. (1985). Designing for Usability: Key Principles and What Designers Think. Communication of the ACM, 28(3), 300-311.

Greenberg, S. & Tauscher, L. (1997). How people revisit web pages: empirical findings and implications for the design of history systems. Human-Computer Studies 47, 97-137.

Gustafson, D.H., McTavish, F.M., Boberg, E., Owens, B.H., Sherbeck, C. & Wise, M. (1999). Empowering patients using computer based health support systems [comment]. Quality in Health Care 8(1), 49–56.

Hall, J.A., Roter, D.L. & Katz, N.R. (1988). Meta-analysis of correlates of provider behaviour in medical encounters. Med Care 26, 657-675.

Hardy, C., Lawrence, T.B. & Phillips, N. (1998).Talk and Actions: Conversations and narrative in inter-organizational collaboration. Discourse and Organizations, 64-83.

Harmsen, J.A.M. (2003).When cultures meet in medical practice (Ph.D. thesis). Rotterdam: Erasmus University.

Hasan, H. & Crawford, K. (2003). A multifaceted approach to distributed communities of learning and practice. Proceeding of the IS Perspectives and Challenges in the Context of Globalization Conference, Athens, for IFIP WG 8.2 and WG 9.4.

Hasan, H. & Crawford, K. (2003). Codifying or enabling: the challenge of knowledge management systems. Journal of the Operational Research Society 54(2), 184-193

Hasan, H., Gould, E., & Hyland, P. (1998). Information systems and activity theory: tools in context, University of Wollongong Press, Wollongong, N.S.W

http://builder.cnet.com/webbuilding/pages/Graphics/Evaluation/�

208

Hasan, H., Gould, E., Larkin, P. & Vrazalic, L. (Eds.), (2001). Information Systems and Activity Theory: Volume 2 Theory and Practice. Wollongong: University of Wollongong Press

Hasan, H. & Gould, E. (1995). The Evolution of an Information System for Managerial Use: A Longitudinal Study, Australian Journal of Information Systems 2(2), 88-93.

Hasan, H. & Gould, E. (2001). Support for the Sense Making Activity of Managers, DSS Journal, special issue on Knowledge Management 31(3), 71-86.

Hasan, H. (1998). Activity Theory: a basis for the contextual study of information systems in organizations. In H. Hasan, E. Gould, & P. Hyland (Eds.), Information Systems and Activity Theory: Tools in Context (pp. 19-38).Wollongong: University of Wollongong Press.

Hasan, H. (1999) Integrating IS and HCI using activity theory as a philosophical and theoretical basis, Australian Journal of Information Systems 6(2), 44-55.

Hertzum, M. & Jacobsen, N.E. (2001). The Evaluator Effect: A chilling fact about usability evaluation methods. International Journal of Human Computer Interaction 13(4), 421-443.

Hewett, R. Baecker, S. Card, T. Carey, J. & Mantei, M. (1996). ACM SIGCHI curricula for human–computer interaction. Association for Computing Machinery, Inc. available at: www. http://sigchi.org.

Hichins, D. (2003). Advanced Systems Thinking, Engineering and Management. Artech House. Boston.

Hickey, M. & Lewandowski, L. (1988). Critical care nurses’ role with families: a descriptive study. Heart& Lung 17,670-676.

Hodovanic, B., Reardon, D., Reese, W. & Hedges, B. (1984). Family crisis intervention program in the medical intensive care unit. Heart& Lung 13, 243-249.

Holden, J., Harrison, L. & Johnson, M. (2002). Families, nurses and intensive care patients: a review of the literature. Journal of Clinical Nursing 11, 140–148.

Holloway, D. (2005). The digital divide in Sydney. Information, Communication &Society 8(2), 168-193.

Homer, J., Hirsch, G., Minniti, M. & Pierson, P. (2003). Models for collaboration: how system dynamics helped a community organize cost-effective care for chronic illness. Proceedings of the 21st International System Dynamics Conference, New York, NY.

Homer, J.B. (1996). Why we iterate: scientific modelling in theory and practice. System Dynamics Review 12(1), 1-19.

Homer, J.B. (1997). Structure, data, and compelling conclusions. System Dynamics Review 13(4), 293-309.

Hughes, F., Bryan, K. & Robbins, I. (2005). Relatives’ Experiences of Critical Care. British Association of Critical Care Nurses, Nursing in Critical Care 10(10), 23-30.

http://sigchi.org/�

209

Hughes, J. & Hill, K. (1998). The political culture of new media users: A snapshot of talk radio and Internet users. Paper presented at the meeting of the Midwest Political Science Association, Chicago.

Huntington, P., Nicholas, D., Homewood, J. & Polydoratou, P. (2003). The general public’s use and perceptions of interactive, personal digital health information and advisory services. (Draft).

Huntington, P., Nicholas, D., Williams, P. & Gunter, B. (2002). Characterizing the health information consumer: an examination of the health information sources used by digital television users. Libri 52 (1), 16-27.

Hupcey, J.E. (1998). Establishing the nurse-family relationship in the intensive care unit. Western Journal of Nursing Research 20(2), 180-194.

Hyland, P. (1998). Exploring some problems in information retrieval: an activity-theory approach. In H. Hasan, E. Gould & P. Hyland (eds.), Information systems and activity theory: tools in context (pp. 93-108). University of Wollongong Press, Wollongong, N.S.W.

Irlam, L. & Bruce, J. (2002). Family-centred care in paediatric and neonatal nursing: a literature review. Curationis: South Africa Journal of Nursing 25(3), 1178-1187.

Irwin, H. (1998). Communication studies in Australia: Tensions and new challenges. Communication Education 47, 247-285.

ISEE Systems. (2006) http://www.iseesystems.com.

ISO 9241-11 (1998). Ergonomic requirements for office work with visual display terminals. (VDTS) Part 11: Guidance on Usability [online]. International Organisation for Standardisation. Available from www.usabilitynet.org/tools/r_international.

Johnson, B.H. (1990). The changing role of families in health care. Children’s Health Care 19, 234-241.

Johnson, I.A. & Adelstein, D.J. (1991). The use of recorded interviews to enhance physician-patient communication. Journal Cancer Education 6, 99-102.

Jun, J., Jacobson, S. and Swisher , J. (1999). Application of discrete-event simulation in health care clinics: A survey. The Journal of the Operational Research Society, 50(2), 109-123.

Kamel Boulos, M.N., Roudsari, A.V., Gordon, C. & Muir Gray, J. A. (2001). The use of quality benchmarking in assessing web sources for dermatology virtual branch library of the National electronic Library for Health (NeLH). Journal of Medical Research, 3(1), available at: www.jmir.org/.

Kaptelinin, V. (1992). Human Computer Interaction in Context: The Activity Theory Perspective, Proceedings of the East-West Intl Conference on Human-Computer Interaction, St Petersburg, Russia, ICSTI, Moscow, 7-13.

Kaptelinin, V. (1996). Activity Theory: Implications for Human-Computer Interaction. In B. Nardi (Ed.), Context and Consciousness (pp. 103-116). MIT Press.

Keogh, S. (2001). Parent’s experiences of the transfer of their child from the PICU to the ward: a phenomenological study. Nurse Critical Care 6, 7-13.

http://www.iseesystems.com/�

http://www.jmir.org/�

210

Kim, D. and Senge, P. (1994). Putting Systems Thinking into Practice. System Dynamics Review 10(2-3): 227-290.

Kim, P., Eng, T.R., Deering, M.J. & Maxfield, A. (1999). Published criteria for evaluation health related web sites: review. BMJ 318(6), 647-9.

Kirk, P., Kirk, I. & Kristjanson, L.J. (2004). What do patients receiving palliative care for cancer and their families want to be told? A Canadian and Australian qualitative study. BMJ 328, 1343: originally published online 19 May 2004;

Kiser, K. (2001). Doctor, Teach Theyself. Online Learning (April), 23-28.

Kittell, R.P, and A. Pallin. 1992. Mercy Hospital: Simulation Techniques for ER Processes. Industrial Engineering. 24(2). 35-37.

Klemm, P., Reppert, K. & Visich, L. (1998). A non-traditional cancer support group. Comput Nurs 16(1), 31–36.

Koller, P.A. (1991). Family needs and coping strategies during illness crisis. AACN Clinical Issues in Critical Care Nursing 2(2), 338-345.

Korpela, M., Soriyan, H. A. & Olufokunbi, K. C. (2000): Activity analysis as a method for information systems development: General introduction and experiments from Nigeria and Finland, Scandinavian Journal of Information Systems 12, 191-210.

Kosco, M. & Warren, N. (2000). Critical care nursers perceptions of family needs as met. Critical Care Nurse Q 23(2), 60-72.

Kuutti, K. & Molin-Juustila, T. (1998). Integrating work activities into a network organisation by a document integration system. In H. Hasan, E. Gould & P. Hyland (Eds.), Information Systems and Activity Theory: Tools in Context, Wollongong University Press.

Kuutti, K., Virkkunen, J. &Young, K. (1995). “Activity” instead of “process”? Questioning the unit of analysis in BPR. Report to the ESPRIT COMIC Project.

Kuutti, K. & Vikkunen, J. (1995). Organisational Memory and Learning Network Organisation: the Case of Finnish Labour protection Inspectors, Proceedings of HICSS28.

Kuutti, K. (1991). Activity Theory and its applications to information systems research and development. In H.E. Nissen, H.K. Klein & R. Hirscheim (Eds.), Information Systems Research: Contemporary Approaches and Emergent Traditions (pp. 529-549). Elsevier, Amsterdam.

Kuutti, K. (1996). Activity Theory as a Potential Framework for Human-Computer Interaction. In B.Nardi (Ed.), Context and Consciousness (pp. 17-44). MIT Press.

Kuuti, K. (1999). Activity Theory as a potential framework for human-computer interaction research. In B. Nardi (Ed.), Context and Consciousness: Activity Theory and Human-Computer Interaction (pp. 17-44) .Cambridge, Massachusetts: The MIT Press.

Lam, P. & Beaulieu, M. (2004). Experiences of families in the neurological ICU: a bedside phenomenon. Journal of Neuroscience Nursing 36(6), 142-162.

211

Landro, L. (2000). Online Data for Health Plans Can Be Great—In Right Doses. Wall Street Journal 20, D 4.

Landro, L. 2003. Health advice abounds on the Net; which web sites can be trusted? The Wall Street Journal, 23 May

Lane, D., Monefildt, G. & Husemann, E. (2003). Client involvement in simulation model building: Hints and insights from a case study in a London Hospital. Health Care Management Science 6(2), 105-116.

Lane, D. & Rosenhead, J. (1998). Emergency- But no accident- A system dynamics study of casualty waiting times in the British NHS, EuroHealth 4, 34-36.

Lane, D.C. (1994). With a little help from our friends: how system dynamics and soft OR can learn from each other. System Dynamics Review 10(2/3), 101-134.

Lane, D.C. (1999). Social theory and system dynamics practice. European Journal of Operational Research 113, 501-527.

Langefors, B. (1973) Theoretical Analysis of Information Systems. Fourth edition, Studentlitteratur: Lund.

Larson, E. (1999). The impact of physician-nurse interaction on patient care. Holist Nurse Practice 13, 38-46.

Laurel, B. (Ed.) (1990). The Art of Human-Computer Interface Design. Addison-Wesley.

Laurel, B. (1993). Computers as Theatre. Addison Wesley.

Law, A. and Kelton, D. (2000). Simulation Modelling and Analysis, Third ed.,McGraw-H ill,New York.

Leape, L. (1997). A systems analysis approach to medical error. J Eval Clin Pract 3, 213–222.

Leape, L. (2002). Reporting of adverse events. N Engl J Med 347(20), 1633–1638.

Lee, S.J. Back, A. L., Block, S. D. & Stewart, S.K. (2002). Enhancing physician-patient communication. American Society of Hematology, 464-483.

Lenvinson, W. Roter, D., Mullooly, J., Dull, V and Frankle, R. (1997). Physician-patient communication: The relationship with malpractice claims among primary care physician and surgeons. JAMA 277, 553-559.

Leonard, A. and Beer, S. (1994).The systems perspective: methods and models for the future, American Council for The United Nations University millennium project, futures research methodology

Leontiev, A.N. (1978). Activity, Consciousness and Personality, Prentice Hall, Englewood Cliffs, NJ.

Leontiev, A.N. (1979). The problem of activity in psychology. In T. V. Wertsch, (Ed.), The Concept of Activity in Soviet Psychology (pp. 37 – 71). New York: Sharpe Inc. Note: originally published in 1972 in Russian in Voprosy filosofii.

Leontiev, A.N. (1981). Problems of the Development of Mind Moscow: Progress.

Leske, J. (1986). Needs of relatives of critically ill patients: a follow up. Heart & Lung 15, 189-193.

212

Lettau, L.A. (1997). Intramural and extramural communication. Infection Control and Hospital Epidemiology 18, 364-368.

Lewis, J.R. (1994). Sample sizes for usability studies: Additional considerations. Human Factors 36(2), 368-378.

Lewis, P. (1993). Linking soft systems methodology with data-focused information systems development. Journal of Information Systems 3, 169-186.

Licker, P. S. (1997), Management information systems: A strategic leadership approach, The Dryden Press, Fort Worth, TX.

Lloyd, M. & Bor, R. (2004). Communication skills for medicine. 2nd ed. Edinburgh; New York: Churchill.

Maani, K. E. & Cavana, R. Y. (2003). Systems Thinking and Modelling: Understanding Change and Complexity, Pearson Prentice Hall Press, Auckland.

Maani, K. E. & Cavana, R. Y. (2005). Systems thinking and Modelling, Pearson, Auckland.

McClement, S.E & Degner, L.F. (1995). Expert nursing behaviours in care of the dying adult in the intensive care unit. Heart Lung 24,408-419.

McClwry, S. (1992). Family functioning during a critical illness: a System Theory Perspective. Care Nurse 1, 115-117.

McGowan, J. & Richwine, M. (2000). Electronic information access in support of clinical decision making: a comparative study of the impact on rural health care outcomes. Proc AMIA Symp 565-569.

McGrath, J.M., Arar, N.H. & Pugh, J.A. (2007). The influence of electronic medical record usage on nonverbal communication in the medical interview. Health Informatics Journal 13(2), 105-117.

McKay, E. (2000b). Measurement of cognitive performance in computer programming concept acquisition: Interactive effects of visual metaphors and the cognitive style construct. Journal of Applied Measurement, 1(3), 257-286.

McKeown, B.F. & Thomas, D.B. (1988).Q Methodology. Quantitative Applications in the Social Sciences 66, Newbury Park, CA: Sage.

McKeown, B.F & Thomas, D.B. (1990). Q methodology. Sage Publications, Newbury Park, California.

McKnight, M. (2006) The Information seeking of on-duty critical care nurses: evidence from participant observation and in-context interviews. Journal of the Medical Library Association 94(2). Health Module pg 145.

Mekhjian, H., Bentley, T., Ahmad, A. & Marsh, G. (2004). Development of a web-based event reporting system in an academic environment. JAMIA 11(1), 11–8.

Meloche, J., Hasan, H. & Mok, M. (2006), Q Methodology for the active process of Knowledge Management, The international journal of knowledge, culture & change management 6(3), 13-18, Australia.

Meloche, J. Hasan, H. & Papakoamas, A. (2004) Support for Asynchronous Interaction in Group Experiential Learning, Outlines Journal of Critical Social Studies. 6(2), 47-62.

213

Meloche, J. & Mok, M. (2005). The Modelling of Information Dissemination: With the ICCMU Website. In P. Petratos and D. Michalopoulos (Eds.), Computer Science and Information Systems (pp. 193-203). Athens, Greece: Athens Institute for Education & Research.

Meloche, J. (1999). Q methodology as a research methodology for human computer interaction. OzCHI’99 Interfaces for the Global Community. Charles Sturt University, Wagga Wagga.

Meloche, J. (2003). The Application of Activity Theory to Investigate Information Seeking: Why is Information Seeking an activity?. In H. Hasan, I. Verenikina & E. Gould (Eds.), Information Systems and Activity Theory: Volume 3 Expanding the Horizon (pp. 233 - 242). University of Wollongong Press, Australia.

Mendonca, D. & Warren, N. (1998). Perceived and unmet needs of critical care family members. Critical Care Nurs Q 21(1), 58-68.

Miles, M.B. & Huberman, A.M. (1994). Qualitative Data Analysis: An Expanded Sourcebook. London: Sage.

Miller, D. & Carlton, K. (1998). Technology as a tool for health care collaboration. Computers in Nursing 16, 27-29.

Miller, T. E. & Derse, A. R. (2002). Between Strangers: The Practice of Medicine Online: A distinction between the provision of information and the practice of medicine is essential to oversight of online medical care. Health Affairs 21(4), 186-179.

Mirr, M.P. (1991). Factors affecting decisions made by family members of patients with severe head injury. Heart Lung 20, 228-35.

Mitchell, M. & Courtney, M. (2005). Improving transfer from the intensive care unit: The development, implementation and evaluation of a brochure based on Knowles' Adult Learning Theory. International Journal of Nursing Practice 11, 257-268.

Molter, N. (1979). Needs of relatives of critically ill patients: a descriptive study. Heart & Lung 8, 332-339.

Morecroft, J. D. W., Jarsen, E. R., Lomi, A. & Ginsberg, A. (1995). The dynamics of resource sharing: A metaphorical model, System Dynamics Review 11(4), 289–309.

Morecroft, J.D.W. and Sterman, J.D. (Eds.) (1994). Modelling for Learning Organizations. Portland, OR Productivity Press.

Morecroft, J. D. W. (1988). System dynamics and micro-worlds for policymakers, European Journal of Operational Research 35, 301–320.

Munn, H.E. (1977). Communication between patients, nurses, physicians and surgeons. Hospital Topics 55, 6-7.

Murray, E., Lo, B. and Pollack, L. (2003). The impact of health information on the internet on the physician–patient relationship: patient perceptions. Arch Intern Med 163, 1727–1734.

Mursu, Á., Luukkonen, I., Toivanen, M. & Korpela, M. (2007). Activity theory in information systems research and practice - theoretical underpinnings for an

https://misprd.uow.edu.au/ris_public/WebObjects/RISPublic.woa/wa/Staff/selectPerson?id=8852&group=84�

214

information systems development model Information Research, 12(3) paper 311 [Available at http://InformationR.net/ir/12-3/paper311.html].

Mutula, S.M. & Wamukoya, J.M. (2007). Web information management: A cross-disciplinary textbook. Chandos Publishing, Oxford. England.

Nardi, B.A & Kaptelinin, V. (1997). Activity Theory: Basic Concepts and Application, Tutorial at CHI97, Atlanta.

Nardi, B.A. & O’Day, L. (1999). Information ecologies: Using technology with heart. Cambridge, MA: MIT Press.

Nardi, B.A. (Ed.) (1995). Context and Consciousness: Activity Theory and Human-Computer Interaction. AP Professional.

Nardi, B., (Ed.) (1996) Context and Consciousness: Activity Theory and Human-Computer Interaction. Cambridge, MA, MIT Press.

Newman, I.A., Parks, L.M., & Smith, P.A. (1997). Virtual hierarchies and virtual networks: some lessons from hypermedia usability research applied to the World Wide Web. Human-Computer Studies 47, 67-95. Academic Press Limited.

Nielsen, J. & Landauer, T.K. (1993). A mathematical model of the finding of usability problems. “Bridges between Worlds”, Proceeding of INTERCHI’93, ACM Press, (pp. 206-221) New York.

Nielsen, J. (1993). Usability engineering. Boston: Academic Press.

Nielsen, J. (1994a). Enhancing the explanatory power of usability heuristics. Proc. ACM CHI'94 Conf. (Boston, MA, April 24-28), 152-158.

Nielsen, J. (1995). Multimedia and Hypertext: The Internet and Beyond. Academic Press.

Nielsen, J. (1995). Usability Engineering. AP Professional.

Nielsen, J. (c2000). Designing Web usability. Indianapolis: New Riders.

Norman, D. (1991). Cognitive Artefacts. In J. Carroll, (Ed.), Designing Interaction: Psychology at the Human-Computer Interface. Cambridge University Press.

Norris, L.O. & Grove, S.K. (1986). Investigations of selected psychosocial needs of family members of critically ill adult patients. Heart & Lung: Journal of Critical Care 15(2), 194-199.

Norum, J., Grev, A., Moen, M., Balteskard, L. & Holthe, K. (2003). Information and communication technology (ICT) in oncology. Patients’ and relatives’ experiences and suggestions. Support Care Cancer 11, 286–293.

Ogata, K. (2004). System Dynamics. Upper Saddle River, N.J.: Prentice Hill.

Ohtaki, S., Ohtaki, T. & Fetters, M.D. (2003). Doctor–patient communication: a comparison of the USA and Japan. Family Practice 20, 276–282.

Oliver, R.L. (1993). A conceptual model of service quality and service satisfaction: combatable goals, different concepts, advance. In Swartz, T.A., Bowen, D.A. & S.W. Brown (Eds.), Services Marketing and Management: Research and Practice (pp. 65-85). JAI, Greenwich City, CT.

http://informationr.net/ir/12-3/paper311.html�

215

Ong, L.M., deHaes, J.C., Hoos, A.M. & Lammes, F.B. (1995). Doctor–patient communication: a review of the literature. Social Science & Medicine 40, 903–18.

Orr, S., Sohal, A.S., Gray, K., Harbrow, J., Harrison, D. & Mennen, A. (2001). The impact of information technology on a section of the Australian health care industry. Benchmarking: An International Journal 8(2), 108-119.

Passik, S.D., Dugan, W., McDonald, M.V., Rosenfeld, B., Theobald, D.E. and Edgerton, S. (1998). Oncologists’ recognition of depression in their patients with cancer. J Clin Oncol 16, 1594-1600.

Pauwels, A. (1995). Cross Cultural Communication in Health Science. Melbourne: MacMillian Education Australia Pty Ltd.

Pew Research Centre for the People and the Press. (1996b, December). News attracts most Internet users [On-line]. Available URL: http://www.people-ress.org/tec96sum.htm

Pew Research Centre for the People and the Press. (1998, June). Internet news takes off [On-line]. Available URL: http://www.people-press.org/med98rpt.htm. (Accessed April 20, 2005).

Pew Internet and American Life Project (Trends). (2005). Internet: The mainstreaming of online life. Available URL: http://pewresearch.org/trends/ trends2005-internet.pdf. Accessed May 14, 2005

Pidd, M. (1994). An Introduction to Computer Simulation. In Proceedings of the 1994 WinterSimulation Conference, (Eds.), J.D. ‘Tew, S.Manivannan, D.A. Sadowski & A.F. Seila. (pp. 7-14).

Pidd, M. (2003), Tools for Thinking - Modeling in Management Science, John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, England.

Preece, J., Rogers, Y. & Sharp, H., Benyon, D., Holland, S. and Carey, T. (1994). Human-Computer Interaction, Addison-Wesley, Wokingham UK

Preece, J., Rogers, Y. & Sharp, H., (2002). Interactive Design: Beyond Human-computer Interaction. John Wiley & Sons, Inc.

Randers, J. (1980). Guidelines for model conceptualisation. In J. Randers (Ed.), Elements of the System Dynamics Method (pp. 117-139). MIT Press: Cambridge, MA.

Randers, J. (1994). Praktisk Prognosearbeid: Eksempler fra Okonomi og Ledelse. Working Paper 84/7, Norwegian School of Management, Oslo, Norway.

Ridell, S. (2005). Mediating the Web as a Public Space. A Local Experiment in the Creation of Online Civic Genres. Nordicom Review 26(1), 31-48.

Richardson, G. & Andersen, D. (1995). Teamwork in group model building. System Dynamics Review 11 (2), 113-137.

Richardson, G. & Pugh, A. (1981). Introduction to System Dynamics Modelling With DYNAMO. MIT Press: Cambridge MA.

Richardson G. (1996). Problems for the future of system dynamics. System Dynamics Review 12(3), 141–157.

http://www.people-press.org/tec96sum.htm�

http://www.people-press.org/tec96sum.htm�

http://www.people-press.org/med98rpt.htm�

http://pewresearch.org/trends/�

216

Richardson, K. (2002). Methodological implications of complex systems approaches to sociality: some further remarks. Journal of Artificial Societies and Social Simulation 5(2).

Richmond, B. (1985). A user’s Guide to STELLA. High Performance Systems, Inc.

Richmond, B. (2004). An Introduction to Systems Thinking, ISEE Systems, Lebanon NH.

Robinson, G.H. (1965). Hospital Admission Scheduling Control. Report No. HFT-65-4, Human Factors in Technology Research Group, University of California, Berkeley.

Rodriguez, J. (1998). Strategies for counterresistance: Toward sociotransformative constructivism and learning to teach science for diversity and for understanding. Journal of Research in Science Teaching 35(6), 589-622.

Royston, G., Dost, A., Townshend, J. & Turner, H. (1999). Using system dynamics to help develop and implement policies and programmers in health care in England. System Dynamics Review 15(3); ABI/INFORM Global pg. 293.

Royston, V. (1997). How do medical students learn to communicate with patients? A study of fourth-year medical students’ attitude to doctor-patient communication. Medical teacher 19, 257-262.

Rubin, J. (1994). Handbook of usability testing: how to plan, design, and conduct effective tests. John Wiley & Sons.

Ruiz-Moral, R., Rodrriguez, E.P., de Toores, L.A. & de la Toores, J. (2006). Physician-patient communication: a study on the observed behaviours of specialty physicals and the way their patients perceive them. Patient Education and Counseling 64, 242-248.

Rukholm, E., Bailey, P., Coutu-Wakulczyk, G., & Bailey, W.B. (1991). Needs and anxiety levels in relatives of intensive care unit patients. Journal of Advanced Nursing 16(8), 920-928.

Sears, A., Jacko, J.A. & Borella, M.S. (1997). Internet Delay Effects: How Users Perceive Quality, Organization, and Ease of Use of Information. Proceedings of CHI '97 2, 353-354.

Senge, P. W. (1990). The Fifth Discipline: The art and practice of the learning organization, Doubleday/Currency, New York, NY.

Senge, P. W. (1992). The Fifth Discipline: The art and practice of the learning organization, Rando House, Sydney.

Senge, P. W. (1994). The Fifth Discipline: The art and practice of the learning organization, Currency Doubleday, New York.

Schneider, C.E. (1998).The Practice of Autonomy: Patients, Doctors and Medical Decisions. New York, NY: Oxford University Press

Schouten, B.C. & Meeuwesen, L. (2005). Cultural differences in medical communication: A review of the literature. Interdisciplinary Social Science Department, Research Institute for Psychology and Health, Utrecht University, Utrecht, The Netherlands.

217

Scott, T., Mannion, R., Davies, H. & Marshall, M. (2003). Implementing culture in health care: theory and practice. International Journal for Quality in Health Care 15, 111-118.

Seidman, I. (1998). Interviewing as Qualitative Research: A Gide for Resaerch in Education & the Social Sciences. New York: Teachers College Press.

Shackel, B. (1989). Ergonomics in Design for Usability. In M.D. Harrison & A.F. Monk (Eds.), People & Computers: Designing for Usability, Proceeding of HCI 86, (pp. 45-64). Cambridge University Press.

Sheer, V.C. & Cline, R.J. (1995). Testing a model of perceived information adequacy and uncertainty reduction in physician-patient interaction. Journal of Applied Communication Research 23, 44-59.

Sheldon, L.K., Barrett, R. & Ellington, L. (2006). Difficult Communication in Nursing. Journal of Nursing Scholarship 38(2), 141-147.

Shellenbarger, S. (2000). More relaxed boomers, fewer workplace frills and other job trends. Wall Street Journal 27, pp.B-1.

Simonds, S. K. (1995). Communication theory and the search for effective feedback. Journal of Human Hyertension 9, 5-10.

Smith, A. (1997). Human-Computer Factors: A study of users and Information Systems. In D.E. Avison, and G. Fitzgerald (Eds.), Information Systems Series (Pg 375) London: The McGraw-Hill Companies.

Smith, M.K. (2003). Communities of practice. The Encyclopaedia of Informal Education, available at: www.infed.org /biblio/communities_of_practice.htm

Söderström, I.M., Benzein, E. & Saveman, B.I. (2003). Nurses' experiences of interactions with family members in intensive care units Scandinavian Journal of Caring Sciences 17(2), 185-192.

Sohal, A. & Ng, L. (1998). The role and impact of information technology in Australian business. Journal of Information Technology 13(3), 201-17.

Somekh, B. & Lewin, C. (Eds.) (2005). Research methods in the social sciences. SAGE Publication Ltd.

Spinuzzi, C. (2001). Grappling with Distributed Usability: A Cultural-Historical Examination of Documentation Genres Over Four Decades. Journal of Technical Writing and Communication 31(1), 41 – 59.

Spyt, T., Watt, P., Boehm, M. & Stafford, P. (2002). Online patient support system-is there a need? British Journal of Clinical Governance 7(4), 250-254.

Star, S.L. (1996). Working Together: Symbolic interactionism, activity theory and information systems. In Y. Engeström and D. Middleton (Eds.), Cognition and Communication at Work (pp. 296-318). Cambridge University Press, NY.

Steinar, K. (1996). Interviews: An Introduction to Qualitative Research Interviewing. Sage Publications, Inc.

Steinberg, E.P., Topol, E.J., Sakin, J.W., Kahane, S.N., Appel, L.J., Powe, N.R., Anderson, G.F., Erickson, J.E. & Guerci, A.D. (1988). Cost and procedure implications of thrombolytic therapy for acute myocardial infarction. J Am Coll Cardiol 12(6Suppl A):58A–68A.

http://www.infed.org/�

218

Stenberg, L. (1980). A modelling procedure for public policy. In J. Randers (Ed.), Elements of the System Dynamics Method (pp. 292-312). Productivity Press: Cambridge, MA.

Stephenson, W. (1953). The Study of Behaviour: Q-technique and Its Methodology, Univ. of Chicago Press, Chicago.

Stephenson, W. (1990). Fifty years of exclusionary psychometrics: I. Q technique. Operant Subjectivity, 13, 105-120.

Stephenson, W. (1990). My self in 1980: A study of culture. Operant Subjectivity 14, 1-19Sterman, J.D. (1984). Appropriate summary statistics for evaluating historical fit of system dynamic models. Dynamica 10, 50-66.

Sterman, J.D. (1994). Learning in and about complex systems. System Dynamics Review 10 (2-3), 291-330.

Sterman, J.D. (2000). Business Dynamics, Systems Thinking and Modelling for a Complex World. McGraw-Hill, London.

Stewart, D. K. (1966). A note about communication research. Journal of psychology 62, 201-203.

Stewart, M.A. (1995). Effective physician-patient communication and health outcomes: a review. CMAJ 152, 1423-1433.

Streubert, H.J. & Carpenter, D.R. (1999). Qualitative Research in Nursing: Advancing the Humanistic Imperative. Philadelphia: Lippincott.

Suratmethakul, W. & Hasan, H. (2004). An Activity Theory analysis of a case of IT-driven organisational change. Proceedings to Decision Support in an Uncertain and Complex World: The IFIP TC8/WG8.3 International Conference.

Swisher, J.S. & Jacobson, S.H. (2002). Evaluating the Design of a Family Practice Healthcare Clinic Using Discrete-Event Simulation. Health Care Management Science 5 (2); ABI/INFORM Global pg. 75.

Taniar, D. & Rahayu, J.W. (2004). Web information systems. Idea Group Publishing, USA.

Taylor, A., Rosegrant, T. & Meyer, A. (1986). Communicating, 4th edn, Prentice Hall, Englewood Cliffs, New Jersey.

Taylor, K.S. & Lane, D.C. (1998). Simulation applied to health services: opportunities for applying the system dynamics approach. J Health Services Res and Policy 3,226-232.

Taylor, M.R., Alman, A. & Manchester, D.K. (2001). Use of the Internet by patients and their families to obtain genetics-related information. Mayo Clin Proc 76, 772–76.

Te’eni, D., Carey, J., and Zhang, P. (2007). Human Computer Interaction: Developing effective organizational information systems. John Wiley & Sons, Inc.

The Harris Poll. (2004). Online Activity Grows as More People Use Internet for More Purposes, number 4.

Thompson, J.P. (1999). Consulting approaches with system dynamics: three case studies. System Dynamics Review 15(1), 71–95.

219

Thorne, S., Hilop, G., Kuo, M. & Armstrong, E. (2006). Hope and probability: patient perspectives of the meaning of numerical information in cancer communication. Qualitative Health Research 16(3), 318-336.

Timmins, F. (2005). A review of the information needs of patients with acute coronary syndromes. Nursing in Critical Care 10(4), 174-183.

Tofts, C. (1993). Process Semantics for Simulation, Technical Report, Department of Mathematics and Computer Science, University of Swansea.

Ton, H., Koike, A., Hales, R., Johnson, J. & Jilty, D. (2005). A qualitative needs assessment for development of a cultural consultation service. Trans-cultural Psychiatry 42(3), 491-504.

Turnbull, E. M. (1992). Student-patient perceptions of communication with physician or nurse practitioner in a university health service setting: Implications for patienthood, pp.303: University of Massachusetts.

Van Horn, E. (2000). The effect of critical care hospitalization on family members: Stress and response. Dimension of Critical Care Nursing 19(4), 40-49.

Van Horn, R.L. (1971). Validation of simulation results. Management Science 17, 247-58.

Vázquez, M., Liz, M. & Aracil, J. (1998). Knowledge and reality: some conceptual issues in system dynamics modelling. System Dynamics Review 12(1), 21-37.

Vennix, J.A.M. (1990). Mental Models and Computer Models: Design and Evaluation of a Computer-based Learning Environment for Policy Making. University of Nijmegen, Netherlands.

Vennix, J.A.M. (1996). Group Model Building. Wiley: Chichester.

Vennix, J.A.M. (1999). Group model building: tackling messy problems. System Dynamics Review 15, 379-401.

Verenikina, I. & Gould, E. (1998). Cultural-historical psychology and activity theory. In H. Hasan, E. Gould & P. Hyland (Eds.), Information Systems and Activity Theory: Tools in Context (pp. 7 – 18). Wollongong, University of Wollongong Press.

Virzi, R.A. (1992). Refining the test phase of usability evaluation: How many subjects is enough?. Human Factors 34(4), 457-468.

Von Gunten, C.F., Ferris, F.D. & Emanuel, L.L. (2000).The patient-physician relationship. Ensuring competency in end-of-life care: communication and relational skills. JAMA 284(23), 3051-3057.

Vygotsky, L.S. (1978). Mind and Society, Cambridge MA: Harvard University Press.

Warren, N. (1993). Perceived needs of the family members in the critical care waiting room. Critical Care Nursing Quarterly 16, 56-63.

Warren, N. (1998). Critical care family members’ satisfaction with bereavement experiences: Development and psychometric of a new instrument (Dissertation) Atlanta Ga: Georgia State University.

Wartofsky, M.W. (1979). Perception, Representation, and the Forms of Action: Towards an Historical Epistemology, (1973) Models, Representation and the Scientific Understanding, Boston: D. Reidel Publishing Co.

220

Washington, G. (2001). Family in crisis. Nurse Management 26, 36-40.

Wearing, M. (1998). Working in Community Services. NSW, Australia: Allen & Unwin

Webster, J. & Trevino, L.K. (1995). Rational and social theories as complementary explanations of communication media choices: two policy capturing studies. Academy of Management Journal 38(6), 1544-1573.

Webster, R. & Williams, P. (2005). An evaluation of NHS Direct online health information e-mail enquiry service: Quality of health information on the internet. Aslib Proceeding, 57(1), 48-62.

Welch, E.W. & Fulla, S. (2005). Virtual interactivity between government and citizens: The Chicago Police Department's Citizen ICAM application demonstration case. Political Communication 22(2), 215–236.

Wertsch, J.V. (Ed.) (1981). The Concept of Activity in Soviet Psychology, Armonk, NY: Sharpe.

Wertsch, J.V. (1985). The Concept of Internalization in Vygotsky's Account of the Genesis of Higher Mental Functions. In J.V. Wertsch, (Ed.), Culture, Communication and Cognition: Vygotskian Perspectives, Cambridge University Press.

Wilson, P. & McNamara, J. (1982). How perceptions of simulated physician-patient interaction influence intended satisfaction and compliance. Soc. Sci. Med 16, p 1699.

Wilson, P. (2002). How to find the good and avoid the bad or ugly. Short health information on the Internet. BMJ 324, 598–602.

Wilson, R., Runamau, W., Gibberd, R., Harrison, B., Newby, L. & Hamilton, J. (1995).The quality in Australian health care study. Medical Journal of Australian 163, 458-471.

Wilson, R. (1998). PILs project report: ensuring the readability, understandability and efficacy of the Phase Two Prodigy non-drug advice leaflets/PILs (Patient Information Leaflets). Sowerby Centre for Health Informatics at Newcastle University, Newcastle, available at: www.schin.ncl.ac.uk/publications_db/pdf/R-29_full.pdf (accessed 1 May, 2003).

Wilson, T.D. (2000). Recent trends in user studies: action research and qualitative methods. Information Research, 5(3), available at: http://informationr.net/ir/5-3/paper76.html (accessed 4 January 2005).

Winefield, H. & Murrell, T. (1992). Verbal interaction in general practice: Information, support and satisfaction. The Medical Journal of Australia 157, 677-682.

Wolstenholme, E. (1990). System Enquiry - A System Dynamics Approach. John Wiley and Sons, Chichester.

Wolstenholme, E. (1999). A patient flow perspective of the U.K. Health Services: Exploring the case for new “intermediate care” initiatives. Systems Dynamics Review 15(3), 253-271.

Wright, L. & Leahey, M. (1994). Nurses and Families: A Guide to Family Assessment and Intervention. Philadelphia:

http://www.schin.ncl.ac.uk/publications_db/pdf/R-29_full.pdf�

http://www.schin.ncl.ac.uk/publications_db/pdf/R-29_full.pdf�



221

Wright, M. (1987). The application of a surgical bed simulation model. European Journal of Operational Research 32, 32-36.

Yoon, S.W. & Kuchinke, K.P. (2005). Systems Theory and Technology: Lenses to analyse an Organization. Performance Improvement 44(4), ABI/INFORM Global pg. 15.

Zabada, C., Singh, S. & Munchus, G. (2001). The role of information technology in enhancing patient satisfaction. British Journal of Clinical Governance 6(1), 9-16.

Zazpe, C. (1996). Información a los familiares de pacientes ingresados en una Unidad de Cuidados Intensivos [Information to ICU patients’ relatives]. Enfermería Intensiva 7 (4), 147–151.

Zhang, J., Johnson, T. R., Patel, V.L. Paige, D. L. & Kubose, T. (2003). Using usability heuristics to evaluate patient safety of medical devices. Journal of Biomedical Informatics 36 (1–2), 23–30.

Zhang, P. & Dillon, A. (2003). HCI and MIS: shared concerns. International Journal of Human-Computer Studies (4), 397–522.

Zhang, Y. (1999). Using the Internet for survey research: a case study. Journal of the American Society for Information Science, 5(1), 57-68.

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APPENDIX I USABILITY TEST SCENARIO1B-ICCMU

Please read the following scenario from the Intensive Care Unit (ICU) of ROYAL PRINCE ALFRED hospital: This is your favourite Aunt Emilie, wife, mother and grandmother. She is one of those people who is always ready to lend a helping hand and look on the bright side of life. She is someone you can go to when you need advice. A couple of years ago she was diagnosed with ovarian cancer for which she quietly

had treatment and got on with her life.

Unfortunately Emilie recently went in for an operation for a recurrence of the cancer. The operation took 4 hours after which the doctor explained that she required resection of an ovarian tumor, part of the large bowel, omentum, and pelvic lymph nodes. A team of physicians from gynecology oncology as well as the colorectal team were involved.

After the procedure Aunt Emilie was admitted to the ICU for further care and management. You visit as often as possible with the rest of the family. The ICU staff tried to be helpful giving you the following information although you will use the Web to find out more. As part of Emilie’s treatment the following instruments were attached to her body:

• two IV lines (intra venous) at both arms, • a Foleys catheter inserted in her bladder, • a colostomy bag at her abdomen, • a drain attached to her abdomen, • a nasogastric tube Puls oximeter attached to her finger.

She was on broad spectrum IV ABs(intravenous antibiotics) , Analgesia, anticoagulant treatment, NBM (nill by mouth) and Intra venous nutrition.

Aunt Emilie stayed in ICU for 9 days with daily blood test for a FBC (full blood count), LFT (liver function test), RFT (renal function test), Electrolytes and Coagulation test.

On Day 5 her condition deteriorated she complained of chest pain, coughs and shortness of breath. Examination reveled tachypnia, tachycardia and low oxygen saturation. The following procedures were done to her: sitting position, Oxygen supply by facial mask ABGs collected (arterial blood gases), CXR (chest X-ray), ECG (electro cardio graph),

Emilie then showed signs of developing pulmonary embolism (PE), so a CTPA ordered for her (computerized tomography pulmonary angiography). The result was positive confirming the diagnosis. She was given a full dose of anticoagulant drugs. to resolve the lung clot.

On Day 9 post operative Emilie was well enough to be transmitted to the ward

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QUESTIONS:

Please use the website to help you answer the following questions about this case: Is the ROYAL PRINCE ALFRED’s ICU the best place for her? Why did Aunt Emilie.t need the post operative admission to the ICU? Why she was deteriorating? What are the risks? What about visiting in the ICU? Who could visit? How long will she remain in ICU after the medical conditions became more complicated? What are the signs of good prognosis?

224

APPENDIX II: USABILITY TEST SCENARIO2B-ICCMU

Please read the following scenario concerning your uncle who required time in the Intensive Care Unit (ICU) of WESTMEAD Hospital:

This is your uncle Jeff, a single father with a young son and daughter. He is like a big brother to you, ready to help you any time you need. He just came back from overseas and you were looking forward to catching up. However before you meet him you heard that he had been admitted to Orange Base Hospital with severe chest pain. You go to the hospital and find out that ECG, CXR and blood tests have been conducted which lead to a preliminary diagnosis of Acute Myocardial Infarction (Heart Attack). Jeff’s condition rapidly deteriorates, necessitating intubation and ventilation and he is transferred to the Intensive Care Unit within 30 minutes of arrival to the hospital. Unfortunately his condition continues

to deteriorate and a diagnosis of cardiogenic shock is made. This means that he needs to be treated in a High Dependency ICU not available in Orange Base Hospital for this reason preparation are commenced to transfer Jeff to Westmead ICU in Sydney for further management. QUESTIONS: Please use the website to help you answer the following questions about this case: Q1: Is the Westmead ICU the best place for your uncle? Q2: What information can you find out about Westmead ICU? Q3: What may happen to your uncle in the ICU? Q4: What more information can you find out about cardiac conditions in general and

heart attacks in particular? Q5: Is it likely that your uncle is suffering pain now? Q6: Is it likely that your uncle need a surgical treatment? Q7: What are the treatment options?

225

APPENDIX III: USABILITY TEST SCENARIO3B-ICCMU

Please read the following scenario concerning your cousin Peter who required time in the Intensive Care Unit (ICU) of ROYAL PRINCE ALFRED hospital:

This is your favourite cousin Peter who loves to play sport. However he has been admitted to hospital many times because he has suffered from Diabetes Mellitus (DM) since he was born but this week he has become very ill. Yesterday Peter was admitted via the Emergency Room to ICU with altered level of consensus, new onset DM and Sever Diabetic keto acidosis (DKA). His condition was seen as critical. The altered level of consensus and critical condition of the patient was attributed to a severe complication called DKA as a result of his underlying disease DM. In DM the body is unable to secrete an important hormone called Insulin, which is important in controlling blood sugar and different vital metabolic

functions in the body. As a result of this, the body is unable to control the sugar in blood that will be high affecting the body electrolytes, fluid movement in body tissues and brain and use of wrong sources of energy leading to harmful waste products. So the main task initially is to control blood sugar and prevent loose of fluid and dehydration. Peter had intravenous lines (IV lines) to supply the adequate amount of insulin and fluids. His blood had to be checked initially every hour and blood electrolytes and PH every 2 hours. He had catheter put into bladder to watch carefully for urine amount. Over 48 hours the blood sugar was brought down to normal ranges and the intravenous insulin was changed to be given under the skin 3 times a day. Peter’s body fluids were corrected, his IV fluids were stopped and the patient was allowed to eat but according to specific diet. On the 3rd day of admission Peter’s general condition improved but he complained of pain then was unable to pass urine. He was found to have rare complication of DKA where the muscles of the body get affected and break down. This material from the muscles is toxic to the kidney and causes renal failure. Peter required (Dialysis), which is a process where the patient’s blood goes through machine that acts like the kidney in cleaning the toxic materials from the blood. His kidneys got better over time and didn’t require more dialysis. Before discharge Peter was taught about the nature of his disease (DM) and the need for long term management with insulin as well as carefully watching his diet.

226

QUESTIONS: Please use the website to help you answer the following questions about this case: Q1: What instruments are used in the ICU for your cousin conditions? Q2: Why do people with Diabetes Mellitus (DM) develop a kidney problem? Q3: What are the expected outcomes of Diabetes Mellitus (DM)? Q4: What further treatment plan may be arranged for him to live a normal life?

227

APPENDIX IV: USABILITY TEST SCENARIO1A- ICCMU

Please read the following scenario concerning a patient who required time in an Intensive Care Unit (ICU) of ROYAL PRINCE ALFRED hospital: A 55 years old female attends the operating theatre for an operation for recurrent ovarian cancer. The operation took 4 hours and required resection of an ovarian tumor, part of the large bowel, omentum, and pelvic lymph nodes. Physicians from gynecology oncology as well as the colorectal team were involved in the operation. After the procedure the patient was admitted to the ICU for further care and management. The following instruments were attached to her body:

• two IV lines (intra venous) at both arms, • a Foleys catheter inserted in her bladder, • a colostomy bag at her abdomen, • a drain attached to her abdomen, • a nasogastric tube Puls oximeter was attached to her finger.

The patient was on broad spectrum IV ABs(intravenous antibiotics) , Analgesia, anticoagulant treatment, NBM (nil by mouth) and Intra venous nutrition. The patient stayed in ICU for 9 days with daily blood test for a FBC (full blood count), LFT (liver function test), RFT (renal function test), Electrolytes and Coagulation test. On Day 5 her condition deteriorated she complained of chest pain, coughs and shortness of breath. Examination revealed tachypnia, tachycardia and low oxygen saturation. The following procedures were done to her: sitting position, Oxygen supply by facial mask ABGs collected (arterial blood gases), CXR (chest X-ray), ECG (electro cardio graph), The patient then showed signs of developing a pulmonary embolism (PE), so a CTPA ordered for her (computerized tomography pulmonary angiography). The result was positive confirming the diagnosis. The treatment was to give her a full dose of anticoagulant drugs in order to resolve the lung clot. On Day 9 post operative the patient was well enough to be transmitted to the Gynecology ward QUESTIONS: Please use the website to help you answer the following questions about this case: Who works in an ICU? Can you find information about ROYAL PRINCE ALFRED’s ICU? Why did the patient need the post operative admission to the ICU? How long can a visitor stay at the bedside? What information can you find about the blood tests that done to the patient?

• ABG • LFT

228

• FBC What is the IDC? What other information can you find that is useful?

229

APPENDIX V: USABILITY TEST SCENARIO2A-ICCMU

Please read the following scenario concerning a patient who required time in the Intensive Care Unit (ICU) of Westmead Hospital: A 45year old male admitted to hospital with severe chest pain. ECG, CXR, blood tests lead to a preliminary diagnosis of Acute Myocardial Infarction (Heart Attack).

The patient’s condition rapidly deteriorates, necessitating intubation and ventilation and he is transferred to the Intensive Care Unit within 30 minutes of arrival to the hospital. Unfortunately the patient’s condition continues to deteriorate and a diagnosis of cardiogenic shock is made. This means that he needs to be treated in a High Dependency ICU not available in Orange hospital. For this reason preparations are commenced to transfer the patient to Westmead ICU in Sydney for further management. QUESTIONS: Please use the website to help you answer the following questions about this case: What information can you find out about Westmead ICU? What may happen to the patient in the ICU? What is a high dependency intensive care unit? What more information can you find out about cardiac conditions in general and

heart attacks in particular? What are the treatment options? What is a ventilator? What is a balloon pump? What blood tests would be performed? What other tests might the patient have?

230

APPENDIX VI: USABILITY TEST SCENARIO3A-ICCMU

Please read the following scenario concerning a patient who required time in the Intensive Care Unit (ICU) of ROYAL PRINCE ALFRED hospital: A 22 year-old male patient was admitted via the Emergency Room to ICU with altered level of consensus, new onset Diabetes Mellitus (DM) and Sever Diabetic keto acidosis (DKA). The patient’s condition was critical. The altered level of consensus and critical condition of the patient was attributed to a severe complication called DKA as a result of his underlying disease DM. In DM the body is unable to secrete an important hormone called Insulin, which is important in controlling blood sugar and different vital metabolic functions in the body. As a result of this, the body is unable to control the sugar in blood that will be high affecting the body electrolytes, fluid movement in body tissues and brain and use of wrong sources of energy leading to harmful waste products. So the main task initially is to control blood sugar and prevent loose of fluid and dehydration. The patient had intravenous lines (IV lines) to supply the adequate amount of insulin and fluids. Patient blood had to be checked initially every hour and blood electrolytes and PH every 2 hours. He had catheter put into bladder to watch carefully for urine amount. Over 48 hours the blood sugar was brought down to normal ranges and the intravenous insulin was changed to be given under the skin 3 times a day. The patient’s body fluids were corrected, his IV fluids were stopped and the patient was allowed to eat but according to specific diet. On the 3rd day of admission the general condition of the patient improved but he complained of pain then was unable to pass urine. He was found to have rare complication of DKA where the muscles of the body get affected and break down. This material from the muscles is toxic to the kidney and causes renal failure. The patient required (Dialysis), which is a process where the patient’s blood goes through machine that acts like the kidney in cleaning the toxic materials from the blood. His kidneys got better over time and didn’t require more dialysis. Before discharge the patient was taught about the nature of his disease (DM) and the need for long term management with insulin as well as carefully watching his diet. QUESTIONS: Please use the website to help you answer the following questions about this case: Q1: Why did the patient require IV lines? Q2: What instruments were used in the ICU? Q3: Why did this patient develop DM? Q4: Why did the patient develop a kidney problem?

231

APPENDIX VII: USABILITY TEST PRE-QUESTIONS-

ICCMU

Activity Theory Usability Laboratory

Name: Date: Pre-test Questionnaire-Test # Scenario # Please answer the following questions by placing a Tick in front of the appropriate answer. What is your age? Your highest level of education is: under 25 years higher school certificate 25-45 year’s University Bachelors degree Over 45 Postgraduate degree How would you describe your Your gender: computer literacy? Female poor Male fair-good expert Your first language: English Other language Do you ever research for medical information for patients in palliative medical conditions? Yes No

232

APPENDIX VIII: USABILITY TEST POST QUESTIONS-

ICCMU

POST-TEST QUESTIONNAIRE

*What is your overall impression to current web site?

*Is there anything that you feel is missing on this site? *Do you agree that web is important and useful? *How the current web site affect your understanding about what was

happened to your relative in ICU? *Did this web help you to absorb the medical language when your patients’ conditions became worse? *What did you like best about the site? *What did you like least about the site? *Do you think that this site is linked to by other useful and credible sites? * Does this web site offer information about support groups or offer virtual or chat support groups? *Does this web site allow for interaction and communicate with the provider of the site, with professional, or with other visitors? *What do you prefer the personal or written info in such crisis situations? * Does access to this web site help to reduce family stress and improve consistency in communication? *Do you agree that web would replace the verbal communication in critical medical environment? * Is there a section on this web site that is devoted to new information regarding health care services? *What are your suggestions to improve the contents of the web? *Do you have any other final comments or questions about this current web site?

233

APPENDIX IX: USABILITY TEST SCENARIO1-

CARESEARCH

Jane is a 64 year-old Sydney woman who has been diagnosed

with 4th stage Breast cancer. Her only close relative, a son, lives

and works inter-state and cannot give her much support.

While she was really shocked after the initial diagnose, she has

always been a strong independent person who as a teacher

always loved her work, her school and her students. But now

after the surgery and the chemotherapy her long term prognosis is not good and she

feels extremely sick and anxious.

Currently she requires assistance with her activities of daily living and for her medical

needs. She realises that her ability to function is decreasing and she need someone to

really listen to her hopes and fears.

She has decided to look for a professional palliative care service that can provide the

medical care she needs at her home and encourage her to cope with this new phase of

her life. See what information is available for her through the Patient’s section of the

Care Search Website.

Q1: How could her find the suitable palliative care within NSW state?

Q2: Is there any online support groups to provide social support?

Q3: She is looking for information about symptoms management?

Q4: Does the web site improve the coordination mechanism between the patients and

their doctors and caregivers?

Q5: Could the patient provide a feedback to the web management?

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APPENDIX X: USABILITY TEST SCENARIO2-

CARESEARCH

Jamie’s father is 70 years old; he was

diagnosed at the age of 65 with

Alzheimer’s disease.

Jamie’s mother had always taken full care

of him because Jamie is a full time worker

and has 3 children. But now his mother is

getting too old to cope.

Both parents now seem to be filled with tension, anxiety and fear and are not able to

deal with important issues. Jamie feels circumstances have changed significantly and

would like to take more responsibility but is not really qualified to cope with two

Alzheimer patients

Doctors said they need help from family and community resources to deal with their

behavioural problems as their need for the medication. A friend told him that there is

state-support that provides palliative care. Jamie wants to know about this, to improve

his knowledge on how to deal effectively with his parents. See what information would

help Jamie in the Families’ section of the Care Search website.

Q1: Need to understand their disease to help them professionally?

Q2: How could I be trained to be a main caregiver for my parents?

Q3: How could help them emotionally, physically and medically?

Q4: How can I cope with the stress and sadness times to be the best caregiver for them?

Q5: Could I have governmental support within Victoria State?

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APPENDIX XI: USABILITY TEST SCENARIO3-

CARESEARCH

Evelyn’s husband Adam is 55 years and was involved in a road traffic accident which has left him suffering from severe brain injury from which there is no chance of recovery. Evelyn is now responsible for the family which consists of five children (three of which are school age). The cost of Adam’s medication alone is just slightly less than his social security income. With

him to look after at their Wollongong home she cannot work. They really needs financial and social support, so Evelyn has decided to look for a live-in palliative care service nearby that the Australian government provides for patients with chronic or advanced illness. See what help you can find for Evelyn on the carer’s section of the Care Search Website.

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APPENDIX XII: CARESEARCH WEB SITE PRE-TEST

QUESTIONS

Activity Theory Usability Laboratory

Name: Date: Pre-test Questionnaire-Test # Scenario # Please answer the following questions by placing a Tick in front of the appropriate answer. What is your age? Your highest level of education is: under 25 years higher school certificate 25-45 year’s University Bachelors degree Over 45 Postgraduate degree How would you describe your Your gender: computer literacy? Female poor Male fair-good expert Your first language: English Other language Do you ever research for medical information for patients in palliative medical conditions? Yes No

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APPENDIX XIII: CARESEARCH WEB SITE POST-TEST

QUESTIONNAIRE

*What is your overall impression to current web site? *Is there anything that you feel is missing on this site? *Do you agree that web is important and useful? *What did you like best about the site? *What did you like least about the site? *Do you think that this site is linked to by other useful and credible sites? * Does this web site offer information about support groups or offer virtual or chat support groups? *Does this web site allow for interaction and communicate with the provider of the site, with professional, or with other visitors? *What do you prefer the personal or written info in such medical situations? * Is there a section on this web site that is devoted to new information regarding health care services? *What are your suggestions to improve the contents of the web? *Do you have any other final comments or questions about this current web site?

web-based information services in critical environments: an

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